Behavior Observation Scale Research Articles

High colour temperature lighting for institutionalised older people with dementia

Non-pharmacologic interventions, such as high-intensity white light with a high output in the short-wavelength part of the spectrum can play an important role in the care for older people with dementia. In order to assess the effects of prolonged exposure to low intensity light, i.e., E < 500 lx, from a light source with a high correlated colour temperature (17,000 K versus 2700 K) on behaviour and circadian rhythmicity of institutionalised older adults with dementia, a cross-over design field study was carried out in a psychogeriatric day care ward in May and June 2008. Effects of the lighting intervention were assessed by the Dutch Behaviour Observation Scale for Intramural Psychogeriatrics (GIP), and tympanic temperature measurements. The two lighting solutions installed, particularly the 17,000 K lighting, led to much lower colour temperatures at eye level in practice. No significant improvements in behaviour and in the range of tympanic temperature were found for the lighting interventions tested. This might indicate that higher illuminance levels are the important factor in establishing successful light therapy, and that higher colour temperature may add up to the effectiveness. At the same time, the 17,000 K light tubes did not result in ultrahigh colour temperatures at the eye level of the subjects, and may even have an adverse effect on some persons with dementia.

The German version of the Anorectic Behavior Observation Scale (ABOS)

To assess the performance of the German version of the Anorectic Behavior Observation Scale (ABOS) as a parent-report screening instrument for eating disorders (ED) in their children. Parents of 101 ED female patients (80 with Anorexia Nervosa; 21 with Bulimia Nervosa) and of 121 age- and socioeconomic status (SES)-matched female controls completed the ABOS. Confirmatory factor analysis supported the original three-factor structure model of the ABOS. Cronbach's alpha coefficients indicated good internal consistency for the three factors and the total score in the total sample. The best cut-off point (100% sensitivity and specificity) in the German version was >or=23. The ABOS may be a useful additional instrument for assessing ED.

Einschätzung kindlichen Essverhaltens durch die Eltern mit einer Kurzform der Anorectic Behaviour Observation Scale

To determine whether the Anorectic Behavior Observation Scale (ABOS) originally developed for clinical purposes can be used in epidemiological studies to assess parents' rating of their child's eating behavior. In a study of 1,057 children aged 10-17 years, the children completed the Eating Disorder Inventory, Child Version (EDI-C), while the parents of 922 children completed the ABOS. The ABOS consists of 30 items, divided into three subscales--unusual eating behaviors, bulimia-like behaviors, and hyperactivity. The data revealed a number of psychometric problems of the ABOS, including variance restriction and extreme distributions. This is due to the checklist design of the ABOS, which generates few "yes" responses in nonclinical populations. Using principal components analysis and confirmatory factor analysis, 10 items were selected that had better psychometric characteristics than the 30-item ABOS while maintaining the same level of validity. This resulted in three subscales similar to the original ones, with 4, 2, and 4 items--eating behavior, bulimia-like behavior, and level of activity/fitness. The short form of the ABOS, called Eating and Activity Questionnaire for Parents (EAQP), is a parsimonious instrument for screening parents' assessments of their child's eating behavior.

4-5세 유아의 창의적 사고와 어머니의 지지적 양육행동 간의 관계

The purpose of this study is to examine 4-5 year older's creative thinking and to investigate the interrelationship between young child's creative thinking and their mother's supportive child-rearing behavior. The subjects were 125 pairs of 4-5 year olders and their mothers in Seoul and Gyeonggi-do. The Multidimensional Stimulus Fluency Measure(Van Hook & Tegano, 2002) was revised and used to measure children's creative thinking. For determining mother's supportive child-rearing behavior, the Child Rearing Behavior Observation Scale (Renshaw & Gardner, 1990) was revised and used. The major results were as follows: first, there is no significant difference between boys and girls, and between the 4 year-olders and 5 year-olders in the "child's creative thinking". Second, when mothers properly keep encouraging children's creative behavior in the course of performing their task, it can significantly effect on the development of their creative thinking.

Ambient bright light in dementia: Effects on behaviour and circadian rhythmicity

Behavioural and psychological symptoms, such as nocturnal restlessness and wandering, are seen in 90% of patients with dementia at some point in their course. Non-pharmacologic interventions, such as high-intensity lighting, can play an important role in managing these behavioural and psychological symptoms by impacting both the visual and the circadian system. In order to assess the effects of prolonged exposure to high-intensity light (about 1800 lx horizontal on table level) on behaviour and circadian rhythmicity of institutionalised older adults with dementia, ceiling-mounted luminaires emitting bluish (6500 K) and yellowish (2700 K) light were installed in an intervention group that was compared to a control group of traditional dim lighting equipment. The study was performed from May to August 2006. Effects of the lighting intervention were assessed by the Dutch Behaviour Observation Scale for Intramural Psychogeriatrics (GIP), and tympanic temperature measurements. In the bluish light scenario, a significant improvement in restless behaviour was observed in the intervention group, as well as a significant increase in the range of tympanic temperature. These effects were not found in the yellowish light scenario. Further evidence is found that high-intensity bluish light may play a role in managing restless behaviour and improving circadian rhythmicity in institutionalised older adults with dementia.

Ontwikkeling van de Gedragsobservatieschaal Psychomotorische therapie voor demente ouderen (GPMT-dem).

PDevelopment of the Behaviour observation scale for Psychomotor Therapy for elderly people with dementia (BPMT-dem).Reliability and concurrent validity This article describes the development of the Behaviour observation scale for Psychomotor Therapy for elderly people with dementia (BPMT-dem). This scale was developed in the late 1980s in order to evaluate the effect of psychomotor group therapy on the cognitive, social, and emotional functioning of elderly people with dementia within the therapy situation.The currently described research investigates inter-assessor reliability and internal consistency of the ten subscales (such as memory, orientation, contact with others, initiative, anxious behaviour, aggressive behaviour) and three domains, as well as the scale’s correlation with other observation scales (concurrent validity) in two different patient groups. The first group consisted of clients receiving psychomotor therapy in a nursing home or a psychiatric hospital (N = 130). Inter-assessor reliability (Cohen’s kappa) varied between 0.27 and 1.00, the internal consistency of the subscales (Cronbach’s alpha) was calculated between 0.46 and 0.86, and that of the domains between 0.76 and 0.81. Based on the findings of this study 15 of the original 88 items were removed, 5 items were moved to other subscales and the text of 2 items was changed. Next, the subscale internal consistency and concurrent validity of this modified (73-item version) BPMT-dem was investigated in a group of 41 elderly participating in a support programme in meeting centres for elderly people with dementia and their caregivers. Cronbach’s alpha for the subscales in this study was calculated between 0.47 and 0.86. To determine concurrent validity, the BPMT-dem was compared with (subscales of) the Assessment Scale for Elderly Patients (ASEP), Behavioural assessment for Intramural Psychogeriatrics (BIP), Brief Cognitive Rating Scale (BCRS) and the Cornell Scale for Depression in Dementia. Correlations with related BPMT-dem subscales varied between 0.38 and 0.75.The inter-assessor reliability and concurrent validity of the 73-item version of the BPMT-dem are satisfactory. The internal consistency of 6 subscales is sufficient, and recommendations are proposed to improve the consistency of the remaining subscales. Further research to test the unidimensionality and scalability of the subscales of the BPMT-dem, as well as the effect of the recommended reformulation and removal of items, is recommended. Before the instrument can be used in actual practice, the psychometric qualities of the BPMT-dem73 need to be studied in a larger and in terms of severity of dementia more heterogeneous study sample, so that statements can also be made on which norms to use in various subgroups of elderly with dementia.Tijdschr Gerontol Geriatr 2007; 38: 88-99

Postoperative continuous intrathecal pain treatment in children after selective dorsal rhizotomy with bupivacaine and two different morphine doses

Children undergoing selective dorsal rhizotomy (SDR) experience severe pain postoperatively; a pain related to both the extensive surgical exposure with multilevel laminectomy and nerve root manipulation. We sought to define an optimal dose of continuous intrathecal (IT) morphine and bupivacaine to treat this severe pain. The aim of this study was to compare two different concentrations of morphine in a fixed dose of bupivacaine with regard to the analgesic effect and survey if they differed in side effects. Twenty-six children, aged 2.7-7.4 years undergoing SDR were included in this study. Postoperatively 11 children received a continuous infusion of morphine 0.4 microg x kg(-1) x h(-1) and bupivacaine 40 microg x kg(-1) x h(-1) (low-dose group) and 15, a continuous infusion of morphine 0.6 microg x kg(-1) x h(-1) and bupivacaine 40 microg x kg(-1) x h(-1) (high-dose group). The Behavioral Observational Pain Scale (BOPS) was used to evaluate pain. Better pain relief was obtained in the high-dose group seen in lower BOPS score compared with the low-dose group [P = 0.03, Fisher's permutation test and P = 0.06 Wilcoxon-Mann-Whitney (WMW) test]. The low-dose group received seven times as much ketobemidone 0.43 +/- 0.54 mg x kg(-1) 48 h(-1) compared with 0.06 +/- 0.09 mg x kg(-1) 48 h(-1) in the high-dose group (P = 0.0005 Fisher's permutation test, P = 0.0017 WMW test). There was no statistical difference in pruritus and postoperative nausea and vomiting between the groups. Respiratory and hemodynamic depression was not found. This study shows that, compared with low-dose, the higher dose of continuous IT morphine combined with bupivacaine, significantly reduce pain score and postoperative intravenous analgesic requirements without increasing adverse effects.

Nature and Development of Huntington Disease in a Nursing Home Population

The Behavior Observation Scale Huntington (BOSH) was developed to obtain a detailed description of the manifestation of Huntington disease (HD) in the final stages. The Unified Huntington's Disease Rating Scale (UHDRS), developed to assess Huntington patients' clinical capacities, does not differentiate adequately in later stages of the disease. A scale easy to administer by nursing personnel for progression of the disease in later stages was needed. Two pilot questionnaires preceded the final version of the BOSH. Observers administered the final version twice independently on 91 patients in 4 nursing homes. The BOSH contains 32 items in 3 subscales: 1) activities of daily living (ADL), 2) social-cognitive functioning, and 3) mental rigidity and aggression. Internal and interrater reliabilities were between 0.83 and 0.95. Rigidity and aggression become more frequent as the disease progresses; later on, this behavior diminishes. Social-cognitive capabilities deteriorate more rapidly in later stages. This study sought to develop a scale for assessing behaviors and individual differences in later stages of HD. The findings support the use of the BOSH in identifying these behaviors and differences.

A combination of tests for the diagnosis of dementia had a significant diagnostic value

ObjectiveTo study the diagnostic parameters of a number of instruments for a diagnosis of dementia in general practice and the added diagnostic value of these tests. Study design and settingCross-sectional diagnostic research in general practice. Participants: 152 persons aged 65 plus. The Mini-Mental State Examination (MMSE), the Clock Drawing Test, the ADMP scale, the Timed Up and Go Test, the Extrapyramidal Sign Scale, the Behavior Observation Scale, the Poon–Baro–Wens computer battery, and the Cognitive Drug Research Computerized Assessment System were evaluated against the Dutch version of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX-N). Diagnostic characteristics were calculated with their 95% CI. Using forward stepwise logistic regression analysis, a model was built with CAMDEX-N as the dependent variable and the tests under study as independent variables. Area under the curve was the main parameter for the comparisons. ResultsThe main diagnostic gain results from age and ADMP, followed by the Clock Drawing Test. Subsequent addition of the MMSE and computer tests results in modest additional gain only. The final model including five tests has an area under the curve of 0.95. ConclusionSophisticated neuropsychological computerized tests have little added value in the diagnostic work-up of dementia in general practice. Basic clinical tests used in an appropriate sequence can be very valuable in establishing the diagnosis of dementia.

Children's Emotional Manifestation Scale: development and testing

The objectives of this study were to develop an objective and operationalized behavioural observation scale that can be used to document children's emotional responses during stressful medical procedures, and to test the psychometric properties of this newly developed scale. The availability of a valid and reliable instrument that accurately documents the manifestation of children's emotions prior to undergoing surgery or during stressful medical procedures is crucial before any intervention can be appropriately planned and evaluated. There is a lack of such an instrument with effective psychometric properties in the literature. A cross-sectional study was employed. A convenience sample of 82 children admitted for day surgery was recruited in this study. Based on systematic literature search, a number of observable emotional behaviours with different levels or intensities were identified. A panel of nurse experts was set up to review this finding and develop the scale. Intra-class correlation was used to estimate the inter-rater reliability coefficient. Internal consistency reliability was assessed by determining the Cronbach's alpha. Content validity was established by six nurse experts' ratings. The validity of the scale was also confirmed by convergent validity. The results showed that there was adequate inter-rater reliability, high internal consistency reliability, good content validity and excellent convergent validity. This study has addressed a gap in the literature by developing an objective tool to document children's emotional responses during stressful medical procedure, which are under-researched in the literature. The Children's Emotional Manifestation Scale was developed to provide a simple, objective and consistent method for nurses to document children's emotional behaviour during stressful medical procedures. Clinical nurses can also use this scale to evaluate preoperative interventions directed towards minimizing anxiety and bolstering coping mechanisms in children undergoing surgery.

Delirium-O-Meter: a nurses' rating scale for monitoring delirium severity in geriatric patients

Delirium is a common psychiatric disorder in general hospital elderly patients. Several delirium screening tests exist. Few nurse based delirium severity measures are available. The aim of this study was to evaluate the Delirium-O-Meter, a new nurses' behavioural rating scale that is an efficient and sensitive measure of delirium severity. Analysis of cross sectional and repeated assessments data. Participants were 92 elderly general hospital patients; 56 with delirium, 24 with dementia or other cognitive disturbances (no delirium) and 12 with other psychiatric disorders or no mental disorder. Measures were the Delirium-O-Meter (DOM), Delirium Rating Scale-Revised version (DRS-R-98), Delirium Observation Scale (DOS), Behavioural observation scale for geriatric inpatients (GIP) and Mini Mental State Examination (MMSE). The majority of DOM items show a (near-) normal score distribution. Reliability of the DOM was high; Cronbach's alpha values ranged from 0.87-0.92; Intra Class Correlation (ICC) range was 0.84-0.91 for total scores and 0.40-0.97 for item scores. Factor analysis produced a 'Cognitive/Motivational' factor explaining almost half of variance and a smaller 'Psychotic/Behavioural' factor. The two-factor model results support the conceptual distinction between hyperactive and hypoactive delirium. DOM observations differentiated delirium from non delirium patients. DOM total scores were highly related to the DRS-R-98, DOS, MMSE and GIP apathy and cognitive sub scales, but less so to the GIP affective disturbances subscale, indicating convergent and divergent validity. Temporal difference scores calculated for DRS-R-98 and DOM assessments on subsequent days were also highly related (rho = 0.80-0.95). The newly constructed DOM is a brief and valid nurses' behavioural rating scale that can be useful for measuring different aspects of delirium and for efficiently monitoring delirium severity in elderly patients.

Behavioral and Mood Effects of Snoezelen Integrated into 24‐Hour Dementia Care

To investigate the effectiveness of snoezelen, integrated in 24-hour daily care, on the behavior and mood of demented nursing home residents. Quasiexperimental pre- and posttest design. Twelve psychogeriatric wards of six nursing homes, spread over different parts of the Netherlands. One hundred twenty-five patients with moderate to severe dementia and care dependency were included in the pretest and 128 in the posttest; 61 were completers (included in both pre- and posttest). Experimental subjects received an individual 24-hour snoezel program, based on family history taking and stimulus preference screening. Caregivers were trained, and (organizational) adaptations were made to fulfill the conditions for resident-oriented snoezel care. The control group received usual nursing home care. Observations were made on the wards using subscales of the Dutch Behavior Observation Scale for Psychogeriatric Inpatients, the Dutch version of the Cohen-Mansfield Agitation Inventory, and the Cornell Scale for Depression in Dementia. Independent assessors observed video recordings of morning care and rated residents' behavior and mood using INTERACT and FACE, respectively. Residents receiving snoezel care demonstrated a significant treatment effect with respect to their level of apathetic behavior, loss of decorum, rebellious behavior, aggressive behavior, and depression. During morning care, the experimental subjects showed significant changes in well-being (mood, happiness, enjoyment, sadness) and adaptive behavior (responding to speaking, relating to caregiver, normal-length sentences). Snoezel care particularly seems to have a positive effect on disturbing and withdrawn behavior. The results suggest that a 24-hour integrated snoezel program has a generalizing effect on the mood and behavior of demented residents.

Developing observational measures of performance in surgical teams.

Team performance is increasingly recognised as an essential foundation of good surgical care and a determinant of good surgical outcome. To understand team performance and to develop team training, reliable and valid measures of team performance are necessary. Currently there is no firm consensus on how to measure teamwork, partly because of a lack of empirical data to validate measures. The input-process-output model provides a framework for surgical team studies. Objective observational measures are needed in surgery as a basis for interdisciplinary team assessment and training. The "observational teamwork assessment for surgery" (OTAS) tool assesses two facets of the surgical process. Observer 1 monitors specific tasks carried out by team members, under the categories patient, environment, equipment, provisions, and communications. Observer 2 uses a behavioural observation scale to rate behaviour for the three surgical phases (pre-operative, operative, and post-operative) with components of teamwork: cooperation, leadership, coordination, awareness, and communication. Illustrative data from an initial series of 50 cases is presented here. The OTAS tool enables two independent observers, a surgeon and psychologist, to record detailed information both on what the theatre team does and how they do it, and has the potential to identify constraints on performance that might relate to surgical outcome.

The use of mediation as a strategy to enhance the development of cognitive flexibility in self-regulated learning

In this paper I discuss mediation as a possible strategy for enhancing cognitive flexibility in self-regulated learning. Although much has been written on the importance of self-regulated learning there is still much debate about the best way of going about developing it. This paper presents empirical qualitative research that focuses on the creation of a complex learning environment that would facilitate the use of mediation as a teaching strategy to develop children's ability to adapt flexibly to the demands of the learning environment. Learning is viewed as a process of holistic personal development rather than the acquisition of knowledge and skills. As part of the design experiment, the Mediational Behaviour Observation Scale (MBOS) was developed to judge the extent to which the researcher's interaction with the learners could be described as mediatory. A qualitative analysis of the MBOS revealed that certain mediatory behaviours were effective in creating a complex learning environment conducive to the development of self-regulated learning. Further interpretative analysis also suggests that mediation can be particularly useful in the development of cognitive flexibility.

Negative symptoms in Alzheimer's disease: a confirmatory factor analysis.

To examine different conceptual models of negative symptoms in Alzheimer's disease. Confirmatory factor analysis of cross-sectional data. Alzheimer patients (n=281) admitted to a psychogeriatric observation ward. Nurses' Behavioural observation scale for psychogeriatric inpatients (GIP). Global clinical ratings of severity of dementia and depression based on the Cambridge Examination for Mental Disorders of the Elderly-Dutch version (CAMDEX-N). A unidimensional model of dementia fitted the data poorly. Multidimensional models produced better results. In two- and three-factor models negative symptoms were separated from cognitive impairment and mood disturbances. The more severe the memory impairment, the more socially withdrawn patients were. In this sense negative symptoms may have been secondary to cognitive decline. However, no association was found between negative symptoms and mood disturbances. Negative symptoms are a prominent clinical feature of Alzheimer's disease and they are related to memory impairment but not to mood disturbances.

Factor-analytic study of the Anorectic Behavior Observation Scale in Japan: comparisons with the original Belgian study

The Anorectic Behavior Observation Scale (ABOS) is a questionnaire developed to obtain information from relatives about behaviors and attitudes of patients with eating disorders. The original report of the ABOS revealed three factors. This is the first study to confirm the factor structure by use of confirmatory analyses. Relatives of 102 patients with eating disorders completed the ABOS, and exploratory factor analyses were performed. Confirmatory factor analyses were performed for this Japanese sample, and the fitness of the factor structure was compared between that in the original report proposed by Vandereycken and that used in the present study. A three-factor structure was revealed by the data of Japanese patients, including factor I (eating behavior meeting the criteria of anorexia; concern with weight, foods, and denial), factor II (bulimia; including bingeing, disposing, furtive eating and purging, and talk about thinness and dieting), and factor III (hyperactivity, eating slowly, and chopping food into very small pieces). Confirmatory analyses supported the improvement of fitness in this modified three-factor structure in comparison with the original three-factor model. This Japanese ABOS study revealed three dimensions, which differed from the original subscales in Belgium. Cross-cultural differences were observed, though the ABOS may be useful in Japan as an instrument for assessing eating disorders.

The Multidimensional Observation Scale for Elderly Subjects (MOSES): studies in adults with intellectual disability

This report describes the results of five studies aimed at evaluating the usefulness, reliability, and validity of the Multidimensional Observation Scale for Elderly Subjects (MOSES) in the assessment of change in ageing persons with intellectual disability. Three hundred and thirty-six individuals with an average age of 49.8 years, including an equal number of men and women, were participants in one or more of the five studies. There were 220 participants with Down syndrome, 81 persons without Down syndrome with intellectual disability, and 35 persons from the general ageing population who were clinically diagnosed with Alzheimer's disease using NINCD/ADRDA criteria. Persons with Down syndrome 40 years of age and older could be distinguished from their younger peers with Down syndrome by statistically significant poorer scores on the MOSES, with those 50 years of age and older showing the worst scores. Comparisons of adults with intellectual disability diagnosed with dementia of the Alzheimer type (DAT), using DSM-IV criteria, with or without Down syndrome, as well as comparisons of patients with clinically diagnosed depression, provided evidence that subtests of the MOSES were sensitive to DAT but less so to depression. These clinical groups also showed significantly poorer scores on the MOSES when compared with those of the normative sample. It was concluded that the MOSES is a behavioural observation scale that can provide useful information in clinical settings as well as in research.

Problem-Solving Team Behaviors

This is among the first studies to develop a typology of performance-relevant team member behaviors from actual observations of intact teams (N = 94) completing a variety of problem-solving tasks. Through a critical incident analysis, behavioral observation scales (BOS) were developed using confirmatory factor analysis. The correlation between BOS and team performance was significant. The typology supports and adds to previous typologies of teamwork behavior. Subsequent cross-validation of the BOS involving 176 team members provided further support for the BOS developed. Next, we used our data to psychometrically evaluate Stevens and Campion’s hierarchical factor structure. Hierarchical confirmatory factor analysis provided support for Stevens and Campion’s model.

Assessment of Children's Social Skills: Recent Developments, Best Practices, and New Directions

This article provides an overview of some of the recent developments in assessing social skills of children and youth, as well as a discussion of "best practices" in conducting assessment and linking assessment to effective intervention. Naturalistic behavioral observation and behavior rating scales are proposed as the 2 assessment methods that should be considered primary or "first-line" choices for social skills assessment. A review of some specific tools that have been developed within these 2 assessment methods is provided. Interviewing and sociometric techniques, although not necessarily primary methods of assessment for children's social skills, sometimes may be an important part of an assessment design, or "second-line" choices. Projective-expressive techniques or objective self-report instruments for assessing children's social skills sometimes may help illuminate the overall assessment results but should never be used as primary assessment methods for social skills; thus, these methods are considered "third-line" methods for this purpose. Six best-practices recommendations, all of which are supported by previous empirical research, are offered for improving social skills assessment efforts. Finally, conclusions are drawn regarding the current state of the art in social skills assessment, as well as implications for future directions in this area. Clearly, the challenge facing researchers and practitioners who are concerned with this area will be to make assessment "functional" and link it to intervention more effectively.

Psychoeducation for the families of patients with eating disorders and changes in expressed emotion: A preliminary study.

Psychosocial variables such as expressed emotion (EE) have prognostic significance, and family psychoeducation has been developed to aid in the treatment of various psychiatric disorders. This study reports relationships among EE, family factors, and symptoms observed while conducting multifamily psychoeducation for eating disorders. Group sessions were held once a month for the relatives of patients with DSM-IV eating disorders, and the group met for five sessions that included both education and problem-solving. Thirty-seven relatives volunteered to participate in our program, and of these, 28 completed the program. EE (as measured by the Five-Minute Speech Sample [FMSS]), family function (as measured by the Family Adaptability and Cohesion Evaluation Scales [FACES]), the family's mental state (as measured by the Profile of Mood States [POMS]), and patient's symptoms (as measured by the Eating Disorder Evaluation Scales [EDES] and Global Assessment of Functioning [GAF] on clinician evaluations, and by the Anorexic Behavior Observation Scale [ABOS] assessment of the family) were administered at both the first and final sessions. The rates of high-EE relatives tended to decrease (especially high emotional overinvolvement [EOI]), and families' assessment of symptoms was also significantly improved. Twice-repeated multivariate analysis of variance (MANCOVA) showed that EOI, ABOS, and POMS scores were changed significantly during the sessions. Psychoeducation for the family members of patients with eating disorders might help lower distress and encourage positive interactions within the family. EE is an important measure in evaluations of psychoeducation. However, a randomized, controlled trial is needed to clarify the efficacy of this treatment.