































Graduate Student Journal of  Psychology
2014, Vol. 15

Copyright 2014 by the Department of  Counseling and Clinical Psychology
Teachers College, Columbia University

31

Parent Education Model for Child & Adolescent 
Onset Psychosis

Elisha Agee, Jaqulyn Spezze, and Justin Underwood
Pepperdine University

Although history has shown that the onset of  psychotic disorders typically begins in early adulthood, recent re-
search has identified a specific population of  children and adolescents who develop psychotic disorders at a young 
age. Children and adolescents who develop psychotic disorders typically have a more complex course and worse 
prognosis than adult onset. For this reason, early intervention can be crucial. Having parents and family mem-
bers who actively participate in the treatment of  patients experiencing psychosis greatly reduces the likelihood 
of  relapse symptoms, while improving the quality of  life of  the patient and the family. This proposed model 
actively engages parents and other family members of  children or adolescents diagnosed with a psychotic dis-
order in different contexts. In the model, families will participate in consultations with the primary treatment 
provider, giving and receiving valuable information about the best possible treatments. Parents will participate in 
caregiver psychoeducation/support groups for additional support from other parents and caregivers with sim-
ilar challenges and needs. Families will also participate in family therapy as a whole in order for the family to 
improve communication, enhance problem-solving skills, and learn how to support the family’s unique needs. 
Having the family involved in these different contexts of  a child or adolescent living with a psychotic disor-
der will not only aid in the treatment of  the disorder but also improve the quality of  life for the entire family.

Parent Education Model for Child & Adolescent 
Onset Psychosis

 Current treatment models available for child and 
adolescent onset psychosis are insufficient and do 
not take a multimodal approach. When addressing 
gaps in the literature in regard to treatment, it is first 
critical to explore and identify theoretical ideas and 
models to ensure that new ideas are philosophical-
ly sound before a new program is actualized. Thus, 
the purpose of  this manuscript is to develop a nov-
el treatment program based on scientific literature 
that would assist clinicians in treating child and ad-
olescent onset psychosis. The proposed treatment 
program is novel because the multiple modalities 
and components of  other treatments that have been 
integrated in the model have been found to be ef-
ficacious. This integration was done in an effort to 
create a single feasible comprehensive program that 
eliminates many of  the research and clinical gaps 
found in single component treatment modalities.

Early-Onset Psychosis

Prevalence & Etiology
 Psychotic disorders such as schizophrenia or 

schizoaffective disorder are serious mental illness-
es that are often pervasive, life long, and crippling. 
Such disorders occur in approximately 1% of  the 
population worldwide and affect not only individual 
patients, but also their family, friends, and com-
munity (Courvoisie, Labellarte, & Riddle, 2001). 
The onset of  psychotic disorders usually occurs 
between the ages of  16 and 30, typically emerging 
much earlier in men than women (McGlashan & 
Johannessen, 1996; Virginia Commission on Youth, 
2010). However, with a growing body of  research, 
child and adolescent onset psychosis is increasingly 
recognized as a distinct phenomenon. Furthermore, 
approximately 39% of  men and 23% of  women 
who develop a psychotic disorder will experience 
their first psychotic episode before they turn 19 
(Davis & Schultz, 1998; Gearing & Charach, 2009; 
Sharma, 2005).
 Child-onset schizophrenia (COS) is extremely 
rare and refers to a child who begins displaying symp-
toms of  psychosis prior to the age of  13 years old 
(Virginia Commission on Youth, 2010). There has 
been variability in the prevalence of  COS. Howev-
er, research typically agrees that COS occurs in ap-
proximately 0.1-1% of  the individuals who develop 
any psychotic disorder (Courvoisie et al., 2001; Shar-
ma, 2005; Virginia Commission on Youth, 2010). 
Adolescent-onset schizophrenia refers to when the 
first psychotic episode occurs between the ages of  
13 and 17, and manifests in approximately 4% of  

Correspondence concerning this article should be addressed 
to: Elisha Agee, Pepperdine University, Graduate School 
of  Education & Psychology, 6100 Center Drive, Los An-
geles, CA, 90045, USA. Email: elisha.agee@gmail.com.



32

individuals with any psychotic disorder (Sharma, 
2005). Although still rare, with the onset of  puber-
ty the incidence of  psychosis rises steadily (Anjum, 
Gait, Cullen, & White, 2010). However, other re-
search has noted that adolescent-onset psychosis 
is “fairly common” (Courvoisie et al., 2001, p. 2). 
When referring to an individual who had their first 
psychotic episode or was diagnosed with a psychot-
ic disorder during either childhood or adolescence, 
the term early-onset schizophrenia (EOS) is used, 
implying that the illness developed prior to the indi-
vidual turning 18 years old (Courvoisie et al., 2001). 
For the purpose of  this paper the term ‘early-onset’ 
will be used to indicate the emergence of  a psychotic 
disorder prior to age 18. Additionally, the term ‘psy-
chosis’ or ‘psychotic disorder’ will be used instead of  
schizophrenia, schizoaffective disorder, or another 
specific type of  a psychotic disorder. The term psy-
chosis is generally used to represent a category of  
disorders. Thus this paper will refer to a category 
of  psychotic disorders, instead of  the various sub-
groups and specific illnesses (Joshi & Towbin, 2002).
 It is not uncommon for individuals to experi-
ence depressive symptoms concurrently with their 
first psychotic episode and symptoms of  early on-
set affective psychoses are very similar to early on-
set nonaffective psychosis, causing a notable amount 
of  misdiagnoses (Schothorst, Emck, & van Enge-
land, 2006). However, the literature on child and 
adolescent onset mood disorders with psychotic 
features is scarce, and much more research has been 
focused on early onset psychosis, without a specif-
ic relationship to mood symptoms (Ledda, Fratta, 
Pintor, Zuddas, & Cianchetti, 2009). Consequently, 
this paper will focus primarily on early onset-psy-
chosis without the presence of  mood symptoms. 
 The rarity of  early onset psychosis (EOP) does 
not reduce the need for researchers and clinicians 
to focus on comprehensive and effective treatment 
protocols. Currently, no interventions have been 
tailored exclusively for children, adolescents, or the 
families affected by EOP (Gearing, 2008). In fact, 
using current treatments for child and adolescent 
psychosis, less than 25% experiencing psychoses ful-
ly recover (Gearing & Charach, 2009). Thus, there is 
a great need to develop a comprehensive treatment 

program that will increase recovery rates for EOP. 
 There are many stressors and issues associated 
with psychotic disorders due to its devastating and 
distressing course, which creates a significant amount 
of  burden on the caregivers and social support of  
individuals suffering from such illnesses. Additional-
ly, hospitalizations often cost a significant amount of  
money, both for the families of  those who are hospi-
talized, and for society at large (Goldberg, 1991). Ado-
lescents experiencing psychotic episodes often require 
hospitalizations ranging from 25 to 45 days in length 
(Gearing & Charach, 2009). Costs associated with psy-
chiatric hospitalizations related to schizophrenia are 
in the tens of  billions of  dollars annually. It is reason-
able to assume that if  hospitalizations associated with 
all types of  psychosis were taken into account, this 
number would increase (Gearing & Charach, 2009). 
 The cost hospitalization is not only financial. 
Secondary effects also occur as the child or adoles-
cent is not in school, and consequently may have 
educational impairments. As a result, there may be 
a discrepancy between the need for, and the avail-
ability of, treatment interventions for parents and 
families managing EOP in children and adolescents.
 The term psychotic refers to the presence of  a 
pre-determined set of  symptoms, such as delusions, 
hallucinations, disorganized speech, and grossly disor-
ganized or catatonic behavior (APA, 2000). Negative 
symptoms may also be present, and reflect the disap-
pearance of  certain abilities and emotions normally 
present  (APA, 2000; Green, 2001). Examples of  neg-
ative symptoms include, flat or blunted affect, alogia, 
and avolition (APA, 2000). More generally speaking, 
it may refer to alterations in typical thought processes 
or disruptions in thinking accompanied by the symp-
toms previously mentioned (Joshi & Towbin, 2002). 
According to the Diagnostic & Statistical Manual, 4th 
Edition, Revised (DSM-IV-TR), the criteria for EOP 
(in schizophrenia in particular) is synonymous with 
the adult criteria for the disorder and can reliably be 
used for children and adolescents (APA, 2000).  The 
only (yet very important) difference is that children 
and adolescents may fail to meet expected social or ac-
ademic milestones. By contrast, the criteria for adults 
include deterioration in functioning (Sharma, 2005). 
 Although there are variations of  terms describ-

AGEE, SPEZZE, UNDERWOOD



33

ing similar psychopathologies, such as psychotic, psy-
chotic disorder, and psychosis, for the purposes of  
this manuscript the term ‘psychosis’ will be used. The 
Diagnostic & Statistical Manual, 5th Edition, was re-
cently published and includes changes to two primary 
psychotic disorders that relate to the idea of  psychosis 
described in this paper. The following changes have 
been made to the schizophrenia category. First, the 
special attribution of  bizarre delusions and Schneide-
rian first-rank auditory hallucinations were removed. 
Second, an individual must have at least delusions, 
hallucinations, or disorganized speech in order to 
be diagnosed (APA, 2013b). Regarding schizoaffec-
tive disorder, once Criterion A has been met there is 
no longer a requirement that a major mood episode 
must be present for the majority of  the disorder’s to-
tal duration (APA, 2013b). Due to the recency of  its 
publication and the fact that research has not yet be-
gun to study the new categories in depth, this paper 
focuses primarily on diagnostic criteria and research 
associated with DSM-IV-TR criteria for psychosis.
 Although the DSM-IV-TR and multiple studies 
have identified the presentation of  EOP as closely re-
sembling adult psychosis, the clinical picture of  EOP 
deviates from adult onset in a variety of  ways (APA, 
2000). A significant difference is that the earlier the 
onset of  psychosis, the more severe the symptoms 
and prognosis appear to be (Anjum et al., 2010; APA, 
2013a; Krausz & Muller-Thomsen, 1993). EOP also 
seems to be paired with a higher prevalence of  nega-
tive symptoms (APA, 2013a; Schothorst, Emck, & van 
Engeland, 2006). Negative symptoms are often diffi-
cult to differentiate from depressive symptoms. How-
ever, negative symptoms often seen in prodromal psy-
chosis include reduced drive, attention problems, and 
anergia, and not affective symptoms such as depres-
sion, or suicidality (McGorry, Yung, Phillips, 2002). 
 Children and adolescents experiencing psycho-
sis may present cognitive impairments such as im-
paired concentration and ability to focus, diminished 
interest, incoherent speech, and confused thinking 
(Joshi & Towbin, 2002; Larson, McGlashan, & Moe, 
1996; Sharma, 2005). Child and adolescent psycho-
sis may also include extreme moodiness such as high 
levels of  anxiety, poor emotional control, bizarre 
and/or stereotypy behaviors, and severe problems 

with building and maintaining friendships (Sharma, 
2005). Delusions and hallucinations may be more 
difficult to assess in children and adolescents per-
haps due to a reluctance to disclose or the more ac-
tive imaginations typically seen during development, 
but they are often present, along with paranoia, “a 
preoccupation with inner thoughts” (p.1), vivid and 
bizarre thoughts and ideas, or an inability to distin-
guish dreams from reality (Sharma, 2005). Further-
more, delusions and hallucinations may be elabo-
rate, with visual hallucinations being much more 
common in children than in adults (APA, 2013).
 As mentioned earlier, the onset of  psychosis typ-
ically occurs between the late teens and mid thirties. 
Although onset prior to adolescence is rare, there 
have been cases of  psychosis documented in as young 
as 5- or 6-year olds (APA, 2000). There are numerous 
etiologic possibilities and the etiology of  many cases 
of  EOP is multifactorial. It is believed that the cause 
of  psychotic disorders most commonly relates to the 
interaction of  genetic influences, biological factors, 
family influences, and environmental factors (Joshi & 
Towbin, 2002; Sharma, 2005). Individuals may also 
experience psychosis as a result of  brain or metabolic 
disorders. There may also be some causes that are still 
unknown. Genetic deficits, prenatal viral infections, 
obstetric complications, and marijuana use during ad-
olescence, have also been associated as risk factors 
and have predictive value for the onset of  psychosis 
(Anjum et al., 2010). Recent research has indicated 
that youths who experience psychotic episodes pri-
or to puberty have an increasing number of  brain 
abnormalities and their brains may have diminished 
brain tissue volume (Commission on Youth, 2010).
 Developmental, environmental, and cognitive in-
fluences may play an even greater role in EOP than in 
adult onset psychosis (Joshi & Towbin, 2002). In fact, 
it has been estimated that in up to 90% of  EOP cases 
there are also behavioral and or developmental abnor-
malities present, such as social withdrawal, disruptive 
behavioral disorders, academic problems, speech and 
language delays, and abnormal brain growth (McClel-
lan & Werry, 2001; Virginia Commission on Youth, 
2010). Also, research has indicated that in children 
under the age of  12, early language deficits and motor 
impairments may precede the first psychotic episode. 

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS



34

It thus appears that the age of  onset of  psychosis may 
have both pathophysiological and prognostic signifi-
cance. Individuals with EOP appear to have poorer 
premorbid adjustment, lower educational achieve-
ment, and more evidence of  brain abnormalities 
(APA, 2000). Further, aside from the strong inverse 
relationship between age of  onset and prognosis, 
those with earlier onset of  psychosis are more often 
males with prominent negative symptoms, cognitive 
impairment, and markedly impaired social func-
tioning (APA, 2000; Gearing, 2008; Sharma, 2005).

Early Intervention & Primary Treatment
 Understanding the course of  psychosis is crucial 
for recognizing and distinguishing the early warning 
signs of  psychosis. The first stage of  the illness is 
referred to as the prodromal stage, and is indicat-
ed by the slow and gradual development of  a vari-
ety of  signs and symptoms prior to development 
of  a full psychosis (Subotnik & Nuechterlein, 1988; 
Morrison et al., 2004). These symptoms consist of  
dysfunctional premorbid development such as so-
cial withdrawal and isolation, academic difficulties, 
deterioration in hygiene and grooming, loss of  in-
terests, shyness, outbursts of  anger, idiosyncratic 
preoccupations and behaviors, and disturbances in 
social behavior (APA, 2000; Joshi & Towbin, 2002). 
 The next stage is called the active stage, some-
times referred to as the acute stage. The active stage 
often consists of  explicit delusions or hallucinations, 
strange or idiosyncratic behaviors, functional de-
terioration, and formal thought disorder (Virginia 
Commission on Youth, 2010; Moukas, Stathopoulou, 
Gourzis, Beratis, & Beratis, 2010). Hallucinations and 
delusions may be less detailed or complex in nature 
for EOP than those observed in adults. Visual halluci-
nations may be more common in EOP (APA, 2000). 
 The recovery phase follows the acute phase 
and describes the time in which symptoms re-
mit and dissipate. In the phase, there may be some 
ongoing symptoms of  psychosis along with con-
fusion, disorganization, dysphoria, and lability 
in mood (Virginia Commission on Youth, 2010; 
Moukas, et al., 2010). The last stage of  psycho-
sis usually consists of  the residual phase, in which 
positive psychotic symptoms are minimal but nega-

tive symptoms may still be present, such as apathy, 
lack of  motivation, social withdrawal, or flat affect.
 It is critical that caregivers are educated to rec-
ognize the early warning signs of  relapse into an-
other episode of  psychosis and to understand the 
course of  the illness. This will allow them to start 
treatment with their child or adolescent as early as 
possible. If  the early warning symptoms of  a re-
lapse are recognized and early assistance and inter-
ventions are implemented, the long and dishearten-
ing course of  the illness and substantial burden on 
the family can be minimized (Kennedy et al., 2008). 
 EOP relapse rates are understudied, but it has 
been indicated that they closely parallel adult relapse 
rates (Gearing, 2008). Current numbers reveal that 
33% of  EOP patients are readmitted to a psychiat-
ric hospital within the first year of  experiencing psy-
chotic symptoms, 44% relapse within 2 years, and 
58% relapse within 5 years of  their first psychotic 
episode (Gearing, 2008). These hospitalizations take 
a toll emotionally on both the youth and the family. 
They also impose a financial burden on the family 
and the health care system. Utilizing therapeutic sup-
ports outside hospital settings reduces the financial 
burden to the family and is overall more cost-ef-
fective (Goldberg, 1991; Weiden & Olfson, 1995). 
Thus, the proposed intervention is a good fit for the 
EOP population and useful to society as a whole.
 Consequently, there is a substantial need for 
parent education and solid treatment interventions 
for children or adolescents diagnosed with EOP in 
order to minimize the possibility of  a relapse. Fur-
thermore, there is a great need for broader education 
about the risk of  EOP, since approximately 39% of  
men and 23% of  women who develop a psychotic 
disorder will experience their first psychotic episode 
before the age of  19 (Davis & Schultz, 1998; Sharma, 
2005). Research has found that caregivers and fam-
ilies with ongoing contact with mental health pro-
fessionals are more likely to better cope and recover 
from the crisis of  having a child or adolescent diag-
nosed with a mental illness. The child or adolescent 
also has a better overall prognosis (Ambikile & Out-
water, 2012). Therefore, this parent education model 
focuses on interventions for individuals experiencing 
EOP and their families. It serves the purpose of  in-

AGEE, SPEZZE, UNDERWOOD



35

creasing their caregiver’s and family’s knowledge of  
the illness, its course, and treatment. In this way, this 
proposed model seeks to help children or adolescents 
with psychosis by assisting their caregivers and fam-
ily, which will in turn assist the child or adolescent. 

Current Theoretical Models of  Treatment

Family Consultation Theoretical Model
 Family consultation is brief, flexible, and utilized 
per the request of  the family that has a child or ado-
lescent experiencing their first episode of  psychosis 
(Lepage, 2005). Consultation is “asking the advice or 
opinion of  an expert and as deliberating together” 
(Marsh, 2001, p.46). Usually, the first intervention the 
family of  a child or adolescent with EOP experiences 
is family consultation. Sometimes it is the only inter-
vention the family encounters that is specifically for 
the family. Family consultations range from one to 
five sessions and typically occur during or after a cri-
sis, child or adolescent inpatient treatments, hospital-
izations, and/or family transitions. Families are then 
referred to long-term treatment (e.g., family therapy, 
couples therapy, National Alliance of  the Mentally 
Ill, and/or individual therapy; Dausch et al., 2012; 
Marsh & Lefley, 2003). Mental health professionals 
perform family consultations, which are first imple-
mented at initial diagnosis or first hospitalization of  
the youth (Lepage, 2005). Both the family members 
and the youth (if  possible) are present in the consul-
tation and the intervention is collaborative in nature.
 The purpose of  family consultations after a 
child or adolescent experiences psychosis for the 
first time is to provide information, expert advice, 
support, and empathy to the family, as well as to im-
prove family coping skills and assist in identifying and 
prioritizing the family’s needs (Marsh, 2001). Family 
consultations provide the means to assist the family 
in formulating a family service plan, addressing ill-
ness-related questions and concerns, and making the 
most informed decision about their child or adoles-
cent and family as a whole (Marsh & Lefley, 2003). 
The consultation also provides a systems oriented 
assessment of  the family’s current needs, concerns, 
strengths, and resources (Marsh, 2001). Furthermore, 
the family consultation is focused on problem res-

olutions and is goal oriented. Topics of  the consul-
tation may include discussing the youth’s substance 
abuse disorder (if  one is present), long-term treat-
ment planning, living arrangements, and psychoedu-
cation about the course of  the illness (Marsh, 2001).
 The consult also emphasizes the family as the 
primary agent of  decision making regarding their 
child or adolescent and also as responsible for im-
plementing those decisions. Research has shown that 
when a family and/or the child or adolescent is in-
formed about early psychosis and about the possible 
medical and psychosocial interventions, they make 
better informed decisions about treatment and fol-
low-up care (Lepage, 2005). Therefore, family con-
sultations appear to be extremely important to in-
clude into the proposed parent and family education 
program. Furthermore, it is suggested that family 
consultations increase the family members’ self-effi-
cacy in caring for their child or adolescent with psy-
chosis (Solomon, Draine, Manion, & Meisel, 1996).

Parent Support Group Theoretical Models
 Current treatments for EOP often include mul-
tiple components, with each component contributing 
a valuable feature to overall management of  the psy-
chosis and its impact on the individual and their family. 
For example, interventions such as day care treatment 
centers may bring relief  to parents by creating a break 
from caregiving and creating valuable time for parents 
to accomplish other responsibilities. Also, providing 
parents time away from caregiving allows them to take 
part in their own income generating activities, which 
can directly help the management of  their child’s ill-
ness due to the staggering costs of  hospitalizations, 
emergency room visits, and medications (Ambikile & 
Outwater, 2012). Group interventions for parents are 
also commonly used and have been found effective. 
 The Family Centered Program is an intervention 
consisting of  a family focused group for youths with 
schizophrenia (Kennedy et al., 2008). The model con-
sists of  6 weeks of  intensive 2-hour group sessions 
followed by six monthly booster sessions. The first 
hour of  each session involves the family meeting to-
gether to learn and practice specific skills pertinent to 
living with a child or adolescent with psychosis. The 
skills taught focus on anger management, stress man-

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS



36

agement, and strategies for coping with problems 
at school and at home. The second hour consists 
of  the family being broken up into smaller groups, 
such as parents and caregivers, and siblings of  the 
individual experiencing the mental illness. Each 
group discusses topics that are relevant to their role 
in the family. For example, the parents’ group focus-
es on mutual support and provides education about 
schizophrenia, symptom management, enhanced 
family communication, and relapse prevention.
 The Psychoeducational Multiple Family Group 
(PMFG) is an approach that is made for various 
models and settings, and is used for integrating care-
givers and family into treatment (Gearing, 2008). It 
is a semi-structured intervention that is flexible and 
focuses on competencies, not deficits, thus directly 
supporting the family. It combines psychoeduca-
tion and therapeutic processes to enable patients to 
engage in behavioral change for the family and the 
child or adolescent with psychosis. PMFG focuses on 
improving communication, medication adherence, 
problem solving, use of  crisis intervention, symptom 
management, and establishment of  social support 
and coping skills (Gearing, 2008). The format con-
sists of  5-8 families attending a closed group over 
a period of  time ranging from 2 months to 2 years.

Family Psychoeducation Theoretical Model
 Psychotic disorders are not completely treatable 
by medication and almost always require adjunctive 
therapies (McFarlane, Dixon, Lukens, & Lucksted, 
2003). Families that participate in such treatment can 
have a significant effect on their relative’s outcome. 
Successful treatment of  a psychotic disorder often 
includes families and significant others involved in 
caring for the patient. They may serve many roles and 
fulfilling these roles can burden the patient’s support 
system, increasing burnout. This burnout often has 
negative effects on the patient’s treatment as well as 
the patient’s and family’s well-being (Adamec, 1996; 
Cochrane, Goering, & Rogers, 1997). However, if  
families are provided with education about the na-
ture of  schizophrenia and possess coping skills spe-
cific to the patient, they can fulfill the above men-
tioned roles while increasing their overall well-being 
(Cuijpers, 1999; Shi, Zhao, Xu, & Sen, 2000). 

 Family psychoeducation provides them with use-
ful information on the nature of  psychosis, its course, 
and successful treatments. It teaches and enhances 
each family member’s ability to cope with their rel-
ative’s confusing illness. Psychoeducation aims to 
encourage families to analyze their behavior toward 
their relative with psychosis, adjust their behavior to 
compensate for their deficits, coordinate the roles 
of  everyone involved in the treatment and rehabil-
itation, and ensure that they are all attempting to 
achieve the same goals in a supportive relationship.
 Practitioners help families create and maintain 
helpful relationships within the family unit. Train-
ing family members to maintain helpful relation-
ships with their relative and to form stable support 
systems is emphasized. The role of  the family as 
directly involved in the treatment of  symptoms is 
deemphasized, leaving that within the scope of  the 
relative with psychosis and his or her treatment team. 
A family’s focus on progress and symptom reduction 
could impede successful treatment, whereas a family 
focused on support could have a very positive effect 
on the patient’s rehabilitation (McFarlane et al., 2003). 
 Families may also require support and a thera-
peutic environment where they can process, grieve, 
and grow. Practitioners provide empathetic engage-
ment with the family, addressing their unique stress-
ors and concerns and providing the continued edu-
cation and ongoing support that is often necessary 
for families (McFarlane et al. 2003).  The interven-
tion with the family also focuses on the enhancement 
of  problem solving skills and improving communi-
cation skills to aid the rest of  the family as a unit. 
Programs that successfully accomplish these goals 
reduce hospitalizations of  the patient, and decrease 
the patient’s positive and negative symptoms, particu-
larly if  the intervention lasts for at least three months 
(Dyck et al., 2000; McFarlane et al., 2003; Pitschel-
Walz, Leucht, Baumi, Dissling, & Engel 2001).

Relapse Prevention Theoretical Model
 Serious mental illnesses, specifically psychosis, 
have periods of  remission or times when there are 
few symptoms present and other times when the 
symptoms are worse or exacerbated (Marsh, 2001). 
Relapse of  a psychotic episode is the reoccurrence 

AGEE, SPEZZE, UNDERWOOD



37

or exacerbation of  psychotic symptoms, which even-
tually leads to interference and impairment in the in-
dividual’s daily living (Levy, Pawliuk, Joober, Abadi, 
Malla, 2012; Addington, Addington, Patten, 2007; 
Moller & Murphy, 1997). Relapse can be associat-
ed with an increased risk of  re-hospitalization, feel-
ings of  hopelessness, fatigue, and a loss of  pleasure 
(Marsh, 2001). However, research has found that 
approximately 93% of  family members can identify 
the warning signs of  a relapse in their relative with a 
psychotic disorder and approximately 80% of  relaps-
es can be prevented (Amenson, 1998). Relapse pre-
vention can significantly reduce the disruption of  the 
family’s lives and also decrease the risk of  re-hospital-
ization of  the relative with psychosis (Marsh, 2001). 
Many variables affect relapse, which include the child 
or adolescent (e.g., prior functioning, coping strate-
gies, substance use, treatment adherence), family (e.g., 
expressed emotion, level of  support), and illness (e.g., 
treatment responsiveness, symptoms) (Amenson, 
1998). Although there are many variables that affect 
the likelihood of  relapse, many of  these variables can 
be modified to develop a relapse prevention plan.  
 Relapse occurs in stages, called the Stages of  
Relapse Model. The five stages of  the relapse model 
are: stability, early warning signs, relapse, symptom 
remission, and recovery (Amenson, 1998). In stability 
(Stage 1) the symptoms are controlled and there is a 
good quality of  life for the child or adolescent. The 
stage of  stability can be maintained if  family mem-
bers and child or adolescent notice and respond to 
the early warning signs (Stage 2) before relapse occurs 
(Stage 3; Marsh 2001). Early warning signs include an 
increase in symptomatology, a change in the child’s 
or adolescent’s behaviors, and alterations in biological 
rhythms (Amenson, 1998). Families can help monitor 
the symptoms, triggers, and warning signs they notice 
in their child or adolescent and also provide support 
and a low stress environment (Marsh, 2001). In relapse 
(Stage 3) the child’s or adolescent’s symptoms are se-
vere and require assistance from the family to obtain 
immediate interventions with their mental health care 
provider (Marsh, 2001). During relapse it is important 
for the family to maintain a sense of  hopefulness for 
the child or adolescent. In symptom remission (Stage 
4) the child or adolescent has to follow the treatment 

regimen given by the treating mental health provider 
and usually appears to be quiet and sometimes dazed 
from the aftermath of  the relapse and trauma of  
relapsing (Marsh, 2001). The child or adolescent is 
at a high risk for relapse during symptom remission 
and also during recovery (Stage 5; Amenson, 1998). 
During recovery the family should focus on healing 
and reintegration of  their child or adolescent. Fur-
thermore, the family should monitor risk factors, 
manage symptoms and triggers, and also enhance 
protective factors (Marsh, 2001). Therefore, this 
program entails increasing knowledge and skills, and 
changing attitudes throughout the treatment process.

The Program

Description
 The proposed model (presented in Figure 1) uti-
lizes a multimodal approach for parents and caregiv-
ers of  children or adolescents with early onset psy-
chosis. Parents and caregivers receive support and 
learn skills in several different contexts. First, parents 
and guardians will participate in family consultations 
with their child or adolescent’s primary treatment 
provider. Parents and caregivers collaborate about 
their child or adolescent’s individual treatment, pro-
viding and receiving important information about 
the treatment of  the psychotic symptoms. Second, 
parents and caregivers participate in parent sup-
port/psychoeducation groups where they learn the 
unique skills needed to aid in their child’s recovery 
while providing a safe space to process the difficul-
ties and frustrations inherent in being a parent or 
caregiver of  a child or adolescent exhibiting psy-
chotic symptoms. Third, parents will attend family 
therapy with their child or adolescent with EOP and 
any other siblings or caretakers of  the child. Fam-
ily therapy allows the family to learn communica-
tion and problem solving skills as the family learns 
to function supportively and address the needs of  all 
its members. Last, relapse prevention interventions 
and techniques will be interwoven and emphasized 
throughout all the aforementioned interventions. 
 The program will last about 3 months, consisting 
of  12 weekly sessions of  parent groups and family 
therapy, and approximately 3-5 family consultations. 

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS



38

However, all services will be available for follow-up 
or “check-in” sessions due to the complexity and 
longevity of  the disorder. Parents and caregivers will 
continue in their role as consultants throughout the 
duration of  their child’s treatment. The target pop-
ulation for this treatment model is parents or care-
givers of  children or adolescents with psychosis who 
are currently under psychiatric care. This treatment 
model also seeks to assist with the child’s or adoles-
cent’s transition from acute inpatient treatment to 
outpatient treatment. Referrals will be made by treat-
ing psychiatrists or psychologists for adjunctive care.
 A primary targeted behavior of  this treatment 
model will be minimization of  psychotic symptoms 
and reduction of  the risk of  relapse. This will be ac-
complished by having all components of  this program 
focusing on symptom management. EOP is com-
prised of  the presence of  positive symptoms, such 
as hallucinations and delusions, negative symptoms 

such as alogia and apathy, and behavioral outbursts, 
which often put the safety of  the child and others at 
risk. Many parents and guardians have reported that 
the presence of  such symptoms affects multiple as-
pects of  their lives, including when these behaviors 
negatively impact individuals outside the family, such 
as neighbors, classmates, and community members. 
(Ambikile & Outwater, 2012). Additionally, family 
support is crucial in the growth and development of  
their children, and is related to whether their child re-
ceives mental health services. Therefore, by integrat-
ing family consultations, parent psychoeducation and 
support, family therapy, and relapse prevention, the 
child or adolescent’s treatment plan will be tackling 
symptom management from several different angles.
 The developmental needs of  children and ad-
olescents will be addressed in the proposed parent 
education model in various manners. The thera-
peutic approach would vary depending on the child 
and adolescent’s developmental stage and the inter-
ventions would be tailored for the child’s or adoles-
cent’s developmental stage. For example, in family 
therapy the interventions and interactions will in-
corporate play therapy for younger children, while 
with adolescents interventions will be based on talk 
therapy. In addition, psychoeducation for the child 
and adolescent will be provided to the child or ad-
olescent in a manner that is understandable to them 
based on their developmental stage (such as language 
abilities, abstract thinking capacity, and so forth).  
 Although not the primary focus of  this paper, a 
critical aspect of  this program entails close communi-
cation and active involvement with the child’s psychi-
atrist to ensure sufficient medication adherence and 
management, should medication be warranted.  The 
Food and Drug Administration has approved the use 
of  some antipsychotic medications in children and 
adolescents with severe emotional disorders such as 
psychosis (Harrison, Cluxton-Keller, & Gross, 2012). 
Both the research regarding medication and the prev-
alence of  medication use among children and ado-
lescents experiencing their first psychotic episode is 
growing, and minors are increasingly being prescribed 
antipsychotic medications as part of  treatment (Coo-
per et al., 2006; Harrison, Cluxton-Keller, & Gross, 
2012). This change is critical since psychotropic med-

AGEE, SPEZZE, UNDERWOOD

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS 
	
  

38	
  

	
  
Figure 1. Description of Proposed Program 
 

 
	
  

	
  
	
  
	
  

	
  
	
  

	
  
	
  
	
   	
   	
  	
  

	
  
	
  
	
  
	
  
	
  

	
  
	
  

	
  
	
  
	
  
	
  
	
  
	
  
	
  

	
  
	
  

	
  
	
  

	
  
	
  
	
  
	
  
	
  
	
  

	
  
	
  

	
  

38	
  

Child or Adolescent’s  
Psychotic Episode 

Referred to program by hospital, 
clinic, or healthcare providers 
recommending adjunctive care 

Family Consultation: 
Parent and child meet with 

professional for 
intake/interviewing and 

assessment (3-5 sessions) 
	
  

Family Therapy: All members in 
the immediate family, including 

patient meet weekly (12 sessions) 

Parent Support/Psychoeducation 
Group: Parents/Caregivers meet 

for two-hour weekly sessions 
(12 sessions) 

Concurrent Treatment Elements: 
 

- Relapse Prevention Emphasis (intertwined in all aspects of treatment) 
- Medication management will continue consistently/paralleled to this program 

	
  



39

ications, particularly antipsychotics, are almost always 
a component of, and by some are viewed as the foun-
dation of, treatment for psychosis (Seligman & Re-
ichenberg, 2007; Zipursky, 2002). Due to the fact that 
children and adolescents with psychosis are a part 
of  a highly vulnerable population that is still grow-
ing and developing, psychiatrists would need to ob-
tain baseline measures before initiating antipsychotic 
medications (e.g., body mass index, liver functioning, 
blood pressure, lipids) and would need to contin-
ue to monitor medically while receiving such med-
ication (Harrison, Cluxton-Keller, & Gross, 2012). 
 Since the majority of  individuals prescribed an-
tipsychotic medication for psychosis are only partial-
ly adherent to their prescribed medication regimen, 
there is an even greater need for this treatment pro-
gram to address and include ways to assess, main-
tain, or increase, adherence to medication as needed 
(Leucht & Heres, 2006). Studies have indicated that 
poor adherence to medication is one of  the major 
predictors of  readmission to the psychiatric hospi-
tal, making individuals three times more likely to be 
admitted than those who are adherent to their medi-
cation treatment (Gearing & Charach, 2009). Within 
the proposed treatment protocol, medication man-
agement would be monitored by the child’s or adoles-
cent’s psychiatrist. However, psychoeducation about 
medication, benefits, side effects, and risk factors, 
would be incorporated into all aspects of  treatment, 
starting with the initial consultation, and continu-
ing in both family therapy and the parent/guardian 
support group. Collaboration with the psychiatrist 
would also be incorporated throughout the pro-
gram, to further benefit from the establishment of  
a cohesive treatment team or wraparound program. 

Structure of  Program

Family Consultation Intervention
 The structure of  the family consultation in the 
presented parent program is empirically supported by 
research. However, it will be modified to specifically 
accommodate families with children or adolescents 
that have recently experienced EOP. The literature on 
family consultation focuses on families with a relative 
that recently experienced their first episode of  psy-

chosis, but it is not specifically geared toward families 
of  children or adolescents. As mentioned, the major-
ity of  first episode psychosis occurs from between 
the ages of  16 and 30 and the incidence of  childhood 
onset of  psychosis is extremely rare. Therefore, most 
resources for parents or caregivers are not geared 
for children or adolescents (under the age of  18), 
highlighting the necessity of  this treatment model.
 The family consultation will range between one 
and five sessions. Since this intervention is flexi-
ble and adaptive, if  it is determined that the fami-
ly needs more consultations due to re-hospitaliza-
tions and/or a crisis, the program can adapt to the 
needs of  the family. The first session of  the family 
consultation usually occurs shortly after the initial 
diagnosis or during the hospitalization of  the child 
or adolescent. There will usually be more than one 
consultation because many times the family will be 
too overwhelmed in the initial consultation to retain 
all the information the consultant offers the fam-
ily and/or the child or adolescent (Lepage, 2005).
 The first consultation will include interviewing 
and assessing the family members and the child or 
adolescent (if  present). The first consultation, and 
all other consultations, will be adjusted to be devel-
opmentally sensitive, such as interviewing the family 
more when the client is younger and using interviews 
that are developmentally appropriate. The first con-
sultation seeks to gather information about the child 
or adolescent, understand what preceded the hospi-
talization, and describe the warning signs the family 
and/or child or adolescent may have noticed before 
the first episode of  psychosis (Lepage, 2005). In ad-
dition, the first family consultation assists in engaging 
the family or caregiver and the child or adolescent into 
treatment during a difficult time in order for them to 
become committed to continue further treatment. 
 In the first consultation, the mental health care 
provider will respond to the family and child or ad-
olescent’s most urgent concerns and needs. The 
consultant will assess the impact the first episode of  
psychosis and hospitalization had on the child or ad-
olescent and the family, their current knowledge of  
psychosis, existing coping skills and social support, 
strengths and weaknesses, and whether or not there 
were any apparent preexisting family stressors (e.g., 

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS



40

life cycle transitions, separation/divorce; Lepage, 
2005). Even in the first consultation, the consultant 
seeks to offer knowledge, advice, and skills to assist 
the family in helping their child or adolescent recov-
er from psychosis. Specifically, the consultant will 
offer education to the family and/or child or ado-
lescent in order to reduce blame and guilt (Lepage, 
2005). The first consultation provides referrals and 
resources to the family or caregiver and child or ad-
olescent, such as information for a case-manager, in 
order to address transportation or insurance issues.
 The second through fifth consultations will vary 
according to the needs of  the child or adolescent and 
their family. In this program, the consultations may 
also include extended family members. If  the child 
or adolescent has siblings, the siblings will be given 
age appropriate information and education regarding 
their sibling’s diagnosis, hospitalization, and treat-
ment plan. Furthermore, parents and siblings will be 
given a tour of  the child inpatient facility in order to 
better inform them and ease their fears about how 
their family member is being treated.  In the later 
consultations the child or adolescent and all family 
members will identify potential relapse signs and be-
haviors, and will also develop a detailed crisis plan. In 
addition, the family, child or adolescent, and consul-
tant will create a discharge plan to transition the child 
or adolescent from inpatient to outpatient treatment. 
There will also be scheduled follow-up consultations 
after the child or adolescent has been discharged from 
the hospital at week one, month one, and as needed.

Parent/Caregiver Psychoeducation & Support 
Group
 One component of  the proposed parent educa-
tion model is a parent and caregiver psychoeducation 
and support group. Psychotic disorders place a signif-
icant burden on family and caregivers due to their fre-
quent onset during late adolescence and their lifelong 
course (Kennedy et al., 2008). Typically, parents and 
primary caregivers are ill prepared for their child’s or 
adolescent’s diagnosis of  a psychotic disorder and 
may not know how to manage the disorder (Gearing, 
2008). Therefore, parent groups can help counter this 
ill preparedness and increase caregivers’ awareness of  
available resources while also incorporating caregivers 

into treatment (Kennedy et al., 2008). Also, involving 
parents of  children or adolescents with psychosis 
in the treatment plan enhances medication adher-
ence and overall prognosis (Gearing, 2008). Such an 
intervention has been shown to be effective in the 
past, and the proposed psychoeducation and support 
group integrates various topics present in past effi-
cacious parent groups (Kennedy et al., 2008). Previ-
ous models have had various durations, such as 6 and 
8 weeks. The proposed group, however, will meet 
for 12 weeks (Gearing, 2008; Kennedy et al., 2008).
 Parents and caregivers will meet once per week 
for 2 hours while their child or adolescent attends 
their typical day program, outpatient treatment, or 
daily routine of  therapy and doctors’ appointments. 
Caregivers will have their experiences normalized, re-
ceive support from people who can relate to those ex-
periences, and hear about other caregivers’ problems 
that they have not experienced but might anticipate. 
The psychoeducational aspect of  the parent group 
is crucial as such interventions for parents and fami-
lies have consistently been correlated with improved 
outcomes and a reduction in relapses and hospitaliza-
tions. Family psychoeducational interventions have 
been found to be more effective in preventing re-
lapse than individual treatment or medication (Gear-
ing, 2008). The support aspect of  the parent group 
will not be separate from, but rather, intertwined 
with the psychoeducational aspect. The integration 
of  support groups and psychoeducation groups 
is not frequently seen, but the need for support is 
not isolated from the other aspects of  the illness or 
the distress being caused by the illness. Therefore, 
by incorporating support into the psychoeducation 
group, an optimal environment will be fostered to 
promote understanding and self-care, and allow for 
experiences to be normalized by other group mem-
bers while learning about the specifics of  the illness. 
The group will be open to parents with children of  
all different ages. The goal is that bringing together 
parents raising children and youth of  different ages 
may provide perspective and offer further support 
to parents from those who have gone through sim-
ilar experiences, both in terms chronological devel-
opment and in the course of  the psychiatric illness.
 The parent group will have a different topic and 

AGEE, SPEZZE, UNDERWOOD



41

theme for each session. The attendees will learn about 
the scheduled topic, and then share their experiences 
and thoughts related to the theme. The following is 
a brief  summary of  some of  the main topics that 
will be covered in the parent group, and the vari-
ous aspects of  each theme that will be emphasized.
 The topic of  ‘Grief ’ will be one of  the first 
themes covered in the parent group. Primary caregiv-
ers often go through the stages of  grief  when their 
child or adolescent is diagnosed with a psychotic dis-
order. Parents often worry about the future life of  
their child or adolescent, and grieve the consequences 
the diagnosis may have on their long-term goals for 
their child, such as working full-time, getting married, 
and having children, often recognizing that such a 
future is now unlikely (Ambikile & Outwater, 2012). 
It will also explore the presence of  grief  in relation 
to accepting their child’s or adolescent’s diagnosis.
 Parents and caregivers will also be taught about 
the symptoms, course, and treatment of  psychosis. 
The opportunity to learn and increase knowledge 
about psychotic disorders and share experiences with 
other parents who also have a child or adolescent 
suffering from a psychotic disorder empowers par-
ents (Gearing, 2008; Kennedy et al., 2008). Educa-
tional material will cover recognition of  early symp-
toms of  relapse, symptom management techniques, 
medication, de-escalating aggressive behavior, and 
communicating with paranoid or psychotic youth.
 The topic of  ‘Emotional Coping’ is another cru-
cial theme that will be covered in the parenting group. 
Significant stress and a spectrum of  emotions often 
occur as a result of  caring for a child or adolescent 
with psychosis. Parents may feel sadness, bitterness, 
guilt, anxiety, fear, anger, and helplessness (Ambikile 
& Outwater, 2012; Gearing, 2008). Coping skills will 
be taught to help parents manage their own emotions 
and reactions. The specific tools that will be taught 
and practiced include relaxation and stress manage-
ment techniques, and changing negative thoughts.
 Children and adolescents in general thrive on 
structure and boundaries, but maintaining structure 
and strict rules is even more essential when raising 
a son or daughter with psychosis. Since children or 
adolescents experiencing psychotic symptoms have 
impaired judgment they may cause serious harm to 

themselves or others. Consequently support and safe-
ty are primary considerations (Joshi & Towbin, 2002). 
Although the hospital is a last resort, parents need 
to be able to recognize when their child or adoles-
cent is extremely stressed and acutely symptomatic, 
and they must be willing to hospitalize their child 
with keeping their child’s best interest in mind. Thus 
the parent group will also teach parents how to set 
boundaries and the importance of  creating and main-
taining structure, because such an environment is 
beneficial for managing psychotic symptoms, partic-
ularly upon discharge from the hospital (Kelly, 2005). 
 Other topics of  the parent group will consist of  
social support and strategies for maintaining a social 
life, coping with stigma, managing economic challeng-
es, problem solving and communication skills train-
ing, and the development of  realistic expectations. 

Family Therapy
 Although information and skills can be crucial 
for successful treatment and significantly improve 
the quality of  life for all involved, families have 
found it difficult to access resources and informa-
tion (Adamec, 1996; Marsh, 1992; Marsh & Johnson, 
1997). Therefore, family therapy can effectively in-
volve the entire family unit and draw upon the family 
psychoeducational theoretical model. Interventions 
will vary according to the child’s or adolescent’s 
stage of  development. For example, families with 
children may utilize elements of  play while families 
with adolescents may utilize more traditional talk or 
dialectic approaches. This mode of  the treatment 
is less structured to allow the family to direct ther-
apy in ways that would be most beneficial to meet 
their needs and provides flexibility to adapt to these 
needs. This allows the family’s cultural values to be 
honored and respected. The family’s values may help 
create coping skills and fulfill unique roles specific 
to the family that has shown an increase in overall 
well-being of  those with psychosis and their fam-
ilies (Cuijpers, 1999; Shi, Zhao, Xu, & Sen, 2000). 
 In these culturally syntonic ways, all family ther-
apy should include some common elements. Edu-
cation about psychosis, its treatment, and guidelines 
to the most successful outcomes should be provid-
ed from the onset in order to disseminate import-

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS



42

ant information through the entire family. Caregivers 
and siblings will learn about the common symptoms 
and courses of  psychotic disorders to help them un-
derstand what they might expect. They will also un-
derstand how the disorder is treated and what some 
of  the most effective treatments look like. Fami-
lies should create a crisis plan so that all members 
know their roles and responsibilities in emergency 
situations. Planning for emergency situations ahead 
of  time can reduce stress during times of  crisis 
and help alleviate fears by normalizing the expec-
tation of  the unexpected (McFarlane et al., 2003).
 Families should engage in enhancing communi-
cation and identifying and solving problems, focus-
ing on the psychosocial rehabilitation in the child or 
adolescent and addressing the needs of  the family. 
Families of  children may focus on safety needs and 
who will be responsible for supervising the child, 
while families of  adolescents may focus more on 
socialization and adaptive coping techniques. The 
therapist will aid the family in identifying strengths 
and needs of  the family. They will then address 
and process issues that are most salient to them as 
they work together in learning to collaboratively 
solve problems. Family therapy can help repair dys-
function in the family unit and encourage growth 
as a unit as family members learn to communicate 
and collaborate together to address the challenges 
that face them both as individuals and as a family. 
 In this approach, emphasis is not placed so 
much on symptoms as it is on enhancing mutu-
al support and increasing well-being and resiliency 
while providing a safe, calm environment that pro-
motes rehabilitation. Specifically, families should 
seek to understand and reduce high levels of  ex-
pressed emotion in order to help facilitate recovery 
and prevent relapse (Wasserman, de Mamani, & 
Guilia, 2012). Time should also be given to address 
feelings of  loss and grief  associated with a diagno-
sis of  a psychotic disorder (McFarlane et al., 2003).
Family therapists must balance the needs of  the fam-
ily as a whole with the specific challenges and needs 
of  a child or adolescent with psychosis. McFarlane 
et al. (2003) gives helpful guidelines for therapists 
conducting the family therapy, suggesting that the 
therapist aid in coordinating all elements of  treat-

ment to understand what goals everyone is working 
toward as they pay attention to the social and clinical 
needs of  the child or adolescent. This is best done 
by exploring the family’s expectations for family ther-
apy and overall treatment and listening as partners 
in treatment planning and delivery. Families should 
also be encouraged to expand their social support 
networks to those who can be empathetic to the 
unique needs and challenges of  families living with 
someone with EOP, such as the National Alliance for 
Mental Illness (NAMI) or other multifamily groups.
 The main objective of  family therapy is to help 
the family function as a unit, both to help facilitate the 
treatment of  EOP as well as to provide the support 
needed for a family living with someone with EOP. The 
family’s needs and solutions are addressed as a whole. 
Individual needs are framed as challenges for the family 
and solutions are generated in order to facilitate unity.           

Assessment of  Outcomes
 In order to assess the parent education program 
the families will be given various measures to complete 
before, during, and after the proposed program. Mea-
sures will focus on quality of  life, level of  functioning 
of  the family, level of  expressed emotion within the 
family, and symptom reduction in the child or ado-
lescent. Specifically, the family will be given the Level 
of  Expressed Emotion scale (LEE), Family Envi-
ronmental Scale (FES), and Quality of  life Interview 
(QOLI) to assess the family’s level of  expressed emo-
tion, family cohesion and conflict, and satisfaction 
with family relationships, respectively (Cole & Kazari-
an, 1988). Furthermore, the child or adolescent will 
be given the Symptom Checklist-90-Revised to mea-
sure psychotic symptoms in addition to several oth-
er symptom scales such as the Positive and Negative 
Symptoms Scale (PANSS) and Brief  Psychotic Rating 
Scale (BPRS). In addition, the frequency and duration 
of  hospitalizations will be monitored and tracked.

Critique of  the Proposed Program

 The parental educational program has several 
strengths not only for the parents or caregivers, but 
also for the child or adolescent with EOP. The first 
strength is that the program is extremely adaptable 

AGEE, SPEZZE, UNDERWOOD



43

and flexible to the needs of  the family and the child 
or adolescent with psychosis. The program dura-
tion, content, consults, and sessions can be adjust-
ed to the needs of  the family and/or child or ado-
lescent. By allowing for individual adaptation and 
deferring to the family’s values, this program may 
be more culturally sensitive than many manualized 
treatments that do not allow for adaptability.  Sec-
ond, the program is multifaceted and offers a vari-
ety of  treatment options that not only addresses the 
parents, but also incorporates the child or adoles-
cent with a psychotic disorder, siblings, and extend-
ed family. Third, the program is developmentally 
appropriate and is composed of  interventions that 
are targeted for families and their children or ado-
lescents under 18 years old. Last, it was developed 
on the foundation of  research supporting the current 
effective treatment components for working with 
a child or adolescent with EOP and their families.
 The program also has some limitations and 
weaknesses. The intervention requires the entire fam-
ily’s participation and makes significant demands of  
their time and energy.  It may be difficult to get the 
“buy in” of  all the family members. For instance, ex-
isting family discord may make it difficult for mem-
bers to cooperate and provide the necessary support. 
Families may also become defensive if  they perceive 
that they are being blamed for their family member’s 
illness. Some family members may take education and 
skills training as being critical of  their role (i.e. judging 
their parenting style or viewing an older sibling as not 
protective enough). It is also possible that the family 
exhibits hopelessness in the face both of  valid con-
cerns and of  stereotypes about serious mental illness. 
Stigma may also prevent some family members from 
wanting to be associated with psychiatric facilities or 
interacting with others who are actively psychotic. Ad-
ditionally, adolescents may worry about losing auton-
omy when the family is involved with their treatment. 
 Furthermore, utilizing multimodal treatments 
requires cooperation and coordination between all 
parties. Families and children or adolescents must 
be flexible to meet several demands. But the pro-
viders must also coordinate treatment and maneu-
ver their schedules to allow families to participate 
in treatment with multiple professionals. Participa-

tion of  these professionals raises the cost for such 
treatments, both in paying the professionals and 
also the cost associated for transportation and work 
missed by parents. In addition, it should be not-
ed that the model does not account for biological 
factors or psychosocial factors other than the fam-
ily. Some patients’ course may respond differently 
based on which of  these components are present.  

Conclusion

 The diagnosis of  a mental illness can be dev-
astating for a child or adolescent and their family, 
particularly if  the disorder is as pervasive, debilitat-
ing, and intrusive as a psychotic disorder.  Current-
ly, there are no treatment models focusing on EOP 
tailored exclusively for children or adolescents and 
their families. This gap may explain the high cur-
rent relapse rate, which results in great financial 
and emotional costs. Consequently, there signifi-
cant need for treatment interventions focusing on 
educating the family on the illness and its conse-
quences, and strengthening family communication 
and functioning, both individually and systemically 
as a family unit. The proposed model seeks to ad-
dress the need for such a parent education program.
 The proposed model was developed on a strong 
foundation of  effective treatment interventions indi-
cated by research and utilizes a multimodal approach 
for parents and caregivers of  children and adoles-
cents with EOP. The model seeks to assist transi-
tion of  the child or adolescent from acute inpatient 
treatment to outpatient treatment. Additionally, all 
components of  this model allow for “follow-up” or 
“check-in” sessions after completion of  the three-
month program. Ultimately, the goal of  this program 
is to minimize psychotic symptoms, reduce the risk 
of  relapse, and increase overall family functioning. 
In sum, the implementation of  this comprehensive 
parent education program model should be consid-
ered by all health care providers when working with a 
child or adolescent experiencing a psychotic episode. 
In the future, it is recommended that this treatment 
model be implemented and studied for its efficacy in 
children and adolescents with early onset psychosis.  

PARENT EDUCATION MODEL FOR EARLY ONSET PSYCHOSIS



44

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