Journal of Pediatric Psychology, Vol. 26, No. 7, 2001, pp. 435-453
© 2001 Society of Pediatric Psychology
Review of Group Interventions for Pediatric Chronic Conditions
Brown University School of Medicine/Rhode Island Hospital
All correspondence should be sent to Wendy A. Plante, Division of Child and Family Psychiatry, Rhode Island Hospital/Brown University School of Medicine, 593 Eddy St., Providence, Rhode Island, 02903. E-mail: Wendy_Plante{at}brown.edu .
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Abstract |
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Objective: To identify treatment studies on group interventions for pediatric conditions and to review their efficacy using standardized criteria.
Methods: Through a systematic literature review, we identified 125 studies describing group treatments for pediatric populations. Group interventions were classified into one of four types of groups distinguished by their primary goals and intended outcomes: emotional support, psychoeducation, adaptation/skill development, or symptom reduction. A fifth category, summer camps, contained elements of the other categories, but due to their unique setting, we considered them separately. Treatments were evaluated and designated as "promising," "probably efficacious," or "well-established," based on the Chambless/Society for Pediatric Psychology criteria.
Results: Group interventions for children and adolescents have been developed to increase knowledge of illness, to increase psychological adaptation, and to decrease physical symptoms and side effects. This literature falls on a broad continuum, ranging from descriptive articles with no empirical assessment of outcome to treatment outcome studies employing randomized control conditions and standardized outcome measures.
Conclusions: Although well-established group interventions do exist, much work is required to establish the efficacy of most group treatments for children and adolescents with chronic illness. Recommendations for improving the status of research are offered.
Key words: pediatric; childhood chronic illness; support groups; group therapy; efficacy.
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Introduction |
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Although individual psychotherapy is the most common format for treatment in clinical settings, nearly half of all child and adolescent clinical treatment outcome studies have assessed the efficacy of treatments provided within a group context (Kazdin, Bass, Ayers, & Rodgers, 1990
). Until the early 1980s, few articles
on group therapy with pediatric populations were published. The first article
describing a group intervention for children and adolescents with medical
illness appeared in 1951 (Dubo,
1951). Perhaps spurred on by the expanding child clinical
literature on groups and the growing use of group interventions with adult
medical populations, the 1980s saw an increase in descriptive accounts and
preliminary evaluations of the use of groups to provide psychological services
to children with chronic illness.
Group treatment may be particularly beneficial to children with medical
conditions for several reasons. Social adjustment is an area of particular
vulnerability for children with chronic illnesses, and peer relationships may
affect adaptation to the disease
(Harbeck-Weber & McKee,
1995). Interacting with peers is a familiar activity that
dovetails with children's developmental needs and typical social context
(Kalogerakis, 1996;
Schaefer, 1999). Groups also
give participants opportunities for modeling, problem solving, helping others,
and relating to peers who share similar circumstances, all of which are more
difficult to arrange through individual therapy
(Citrin, Zigo, LaGreca, & Skyler,
1982; Gilbert,
1990; Schaefer,
1999).
The goal of this article is to identify and systematically evaluate group
interventions developed for pediatric populations. Thus far, the published
articles on empirically supported treatment in pediatric psychology have
focused on specific diagnoses (Spirito,
1999), and there have been no reviews of group interventions that
may be applied across pediatric populations and problems. Because reports
about group interventions are often published in journals devoted to a
specific disease (e.g., Diabetes Care, Headache), this article
consolidates information from separate literatures so that researchers and
practitioners seeking treatment models to apply to one pediatric population
may borrow from models that have yielded good outcomes with other populations.
We hope that highlighting gaps and suggesting future directions in the
empirical evaluation of pediatric treatment groups will stimulate systematic
research on this treatment modality.
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Literature Search |
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We generated a comprehensive list of pediatric populations for which psychological treatment might be sought. Relevant articles about pediatric group interventions were then identified for each medical condition using Psychlit and Medline, computerized databases of psychological and medical literature. Search parameters included the name of the chronic illness or disability (e.g., asthma, cerebral palsy) paired with phrases related to group psychological treatments (i.e., group treatment, group therapy, group psychotherapy, group intervention, camp). In addition, "pediatric," "children," and "adolescents" were used as key words to exclude articles about group treatments for adult populations. Reference lists within the obtained primary and review articles then were searched for other relevant publications.
To be eligible for inclusion, an article had to be published in English in a peer-reviewed journal between 1970 and 2000. The participant sample had to consist of children or adolescents (birth to age 18 years) with an identified medical problem. A psychological intervention had to have been administered in a group format to the identified patient group with the goal of improving psychological adjustment to the illness or reducing physical symptoms. Interventions that included a collateral parent- or family-group component were also included, but parent groups existing in the absence of direct treatment for patients were excluded. The methodological rigor of the studies was not a criterion for inclusion or exclusion.
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Methodological Criteria |
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We classified the group interventions into one of four types of groups distinguished by their primary goals and intended outcomes: emotional support, psychoeducation, adaptation/skill development, and symptom reduction. A fifth type of group, summer camps, contained elements of the four categories, but due to their unique setting, we considered them separately. Emotional support groups, symptom reduction groups, and summer camps were easily distinguished from one another and categorized. Psychoeducational groups and adaptation/skill development groups emphasize enhancing psychosocial adaptation to the illness/condition. Their distinguishing feature was whether the secondary goal of the intervention was provision of information about the illness and its management or the development and practice of specific skills that could lead to better management of the illness.
Studies within each category were evaluated using the Society for Pediatric
Psychology (SPP) modifications (Spirito,
1999) to the criteria for empirically supported treatments
outlined by the Task Force on Promotion and Dissemination of Psychological
Procedures (1995;
Chambless et al., 1996),
hereafter referred to as the Chambless/SPP criteria.
Well-established treatments have at least two good between-group design experiments or at least nine single-subject experiments demonstrating (1) the superiority of an intervention to pill, psychological placebo, or alternative treatment or (2) equivalence to an already established treatment. Experiments are conducted with treatment manuals or with a specified treatment protocol; characteristics of the client samples are clearly specified; and effects are demonstrated by at least two different investigative groups. Probably efficacious interventions have at least two experiments showing the treatment is more effective than a waiting-list control, or one or more experiments meeting the criteria for a well-established treatment conducted by the same investigative group. Promising interventions have at least one well-controlled study and another less rigorously controlled study by a separate investigator, or two or more well-controlled studies with either small sample size or conducted by the same investigative group.
We used the Chambless/SPP criteria to evaluate the body of literature for each type of group intervention (e.g., emotional support vs. symptom reduction) as applied across pediatric chronic conditions. Where possible, however, we also evaluated the efficacy of group interventions within specific conditions.
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Results |
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Emotional Support Groups
The primary goal of emotional support groups is to improve psychological adaptation to illness by providing contact and discussion with others in similar situations. Emotional support groups explicitly and exclusively emphasize providing support, as opposed to providing information or modifying specific skills or symptoms. We identified 27 articles describing emotional support groups for children and adolescents with cancer, cystic fibrosis, diabetes, seizure disorders, headache, HIV, neuromuscular disorders, renal disease, sickle cell disease, and heterogeneous diagnoses. Across all diseases, most articles on emotional support groups were descriptive. The formats ranged from unstructured play or expressive art groups (e.g., Kriestmeyer & Heiney, 1992) to semistructured discussion groups (e.g., Brown, Krieg, & Belluck, 1995
; Heiney, Wells, Coleman,
Swygert, & Ruffin, 1990).
We identified three studies that attempted to empirically evaluate the
impact of emotional support groups on adolescents with cancer and sickle cell
disease, and one in which a support group was compared to self-help relaxation
treatment for adolescents with headache. Baider and De-Nour
(1989) offered group treatment
to 16 adolescents and young adults with cancer, only half of whom were willing
to join. Those who refused to join the group were diagnosed more recently.
Results depended on participants' stage of treatment. Group participants in
active treatment reported pre-post increases in psychological symptoms whereas
group participants no longer in active treatment reported pre-post decreases
in psychological symptoms. Clark and colleagues
(1992) described a unique
adolescent support group that incorporated healthy high school students, first
in preparing a documentary for a video production class, then by participating
jointly in a support group for over 2 years. Positive effects were noted on a
post-hoc, nonstandardized survey of perceived impact. Telfair and Gardner
(1999) presented an
uncontrolled evaluation of 12 existing community and hospital-based support
groups for adolescents with sickle cell disease. On average, the groups met
monthly and had been operating for 3 years. Satisfaction with the group
correlated positively with physical and psychological well-being and moderated
an association between pain and well-being. A support/problem-discussion group
was used as a control condition and compared to an individually based
self-help relaxation treatment for headaches
(Larsson, Melin, Lamminen, & Ullstedt,
1987). The support/discussion group resulted in no pre-post
changes in headache symptoms.
Support groups exist because of the widely accepted belief that meeting and talking with other people who understand and share one's unique experiences and challenges with illness can be psychologically comforting and instrumentally useful. To date, there have been no well-controlled studies of the psychological or physical impact of emotional support groups with pediatric populations. Thus, currently, emotional support groups do not meet minimal Chambless/SPP criteria for empirical validation.
Psychoeducational Groups
The primary goal of psychoeducational groups is to enhance psychological
adjustment to illness by providing information about the illness and its
management as well as discussion of social and psychological issues. We
identified four articles describing such groups for children and adolescents
with asthma, diabetes, HIV/AIDS, and sickle cell disease. One was purely
descriptive (Bacha, Pomeroy, & Gilbert,
1999), and another could only highlight the patient and systems
factors that interfered with successful implementation and evaluation of the
group (Ceccoli, 1992). One
(Wamboldt & Levin, 1995)
presented positive results of a post-hoc survey of the perceived impact of a
brief (5-hour) interdisciplinary intervention with 72 families of children
with asthma. The final study (Boroffice,
1992) randomly assigned 56 adolescents with sickle cell disease to
a psychoeducational group, an education-only group, or a wait-list condition.
Participants completed a pre-post questionnaire assessing attitude toward
medical services. A pill count method assessed adherence to medical regimen.
As compared to controls, both treatment conditions improved attitudes and
adherence.
Psychoeducational groups also have served as controls for other treatments
for children and adolescents with diabetes. We included five such articles in
our discussion because the analyses provided data regarding the efficacy of
the psychoeducational groups themselves. Twenty-one adolescents were randomly
assigned to a psychoeducational or a social learning group, both 3 weeks long
(Kaplan, Chadwick, & Schimmel,
1985). The psychoeducational group showed slight pre-post
increases in blood glucose (HbA1) and had significantly higher
HbA1 than the social learning group, who showed slight decreases in
pre-post HbA1. Wysocki et al.
(1997,
1999,
2000) compared a
psychoeducational group to behavioral family systems therapy (BFST), and
standard medical care for adolescents with poorly controlled diabetes living
within highly conflicted families. Both the psychoeducational group and BFST
resulted in improved self-reports of global parent-adolescent conflict.
Psychoeducational groups did not alter adherence, self-reports of
diabetes-specific conflict (Wysocki et
al., 2000), or observed family communication and conflict
resolution skills (Wysocki et al.,
1999). Consumer satisfaction and evaluation were better for BFST
than for the psychoeducational groups
(Wysocki et al., 1997).
In summary, psychoeducational groups may be equivalent to education-only groups in improving attitudes toward medical services and adherence to regimen and may be equivalent to family-based behavioral therapy in reducing global family conflict. However, they do not appear effective in improving symptoms. Given the variation in clinical populations and outcome measures and the lack of well-controlled studies, psychoeducational groups do not currently meet minimum Chambless/SPP criteria for efficacy.
Adaptation/Skill Development Groups
Adaptation/skill development groups are those with the dual goals of
enhancing psychosocial adaptation to the condition and improving physical
symptoms by enhancing specified skills. We found 14 studies on asthma, cancer,
and diabetes that met these criteria. The skills targeted included family
communication and functioning, social skills, problem-solving skills, symptom
monitoring, and skills directly related to managing physical symptoms (e.g.,
improving diet). Formats of these groups included child/adolescent groups
only, child/adolescent groups with collateral parent groups, and multifamily
groups in which children and their parents met in a group of several families
together.
The cancer group (Kazak et al.,
1999) was unique in its focus on a potential
psychological side effect of the disease and treatment, posttraumatic
stress disorder (PTSD) symptoms, whereas the other studies targeted physical
symptoms. A multifamily format was combined with a cognitive-behavioral
approach to reduce anxiety and PTSD symptoms and to increase communication and
perceptions of social support in adolescent patients and their families. The
pilot intervention provided information on PTSD symptoms, discussion of impact
of cancer on the family, and instruction in cognitive coping skills and
generalization of new skills to home life. At 6 months postintervention, there
were decreases in anxiety and PTSD symptoms in all family members and
improvement in family functioning in selected domains.
Two studies targeted family functioning to improve psychological adjustment
and diabetes management via multifamily groups. Groups that focused on family
communication and conflict resolution improved diabetes attitudes, adherence,
and metabolic control when groups were small (three to four families) and when
parents had opportunities to experience diabetes self-care through simulation
(Satin, LaGreca, Zigo, & Skyler,
1989). A pilot study with small sample sizes reported greater
improvements in the parent-teen relationship and a trend for better adherence
for adolescents who participated in behavioral multifamily groups followed by
a separate adolescent discussion group than for adolescents randomized to
standard outpatient medical care (Delameter et al., 1991). Based on these
results, the use of focused multifamily groups for adolescents with poorly
controlled diabetes does not currently meet minimum Chambless/SPP criteria for
empirical validation, as only one study documented their superiority over a
no-treatment condition.
Nine studies targeted coping skills such as social problem solving, stress
management, and behavior change. In youngsters with diabetes, decreases in
perceived stress (Boardway, Delamater,
Tomakowsky, & Gutai, 1993) and improvements in knowledge
(Gross, Magalnick, & Richardson,
1985), adherence (Gross,
1982; Gross et al.,
1985), social skills (Gross,
Heimann, Shapiro, & Schultz, 1983;
Gross, Johnson, Wildman, & Mullett,
1981), metabolic control
(Grey, Boland, Davidson, Yu, &
Tamborlane, 1999; Gross et
al., 1985; Kaplan et al.,
1985), and quality of life
(Grey et al., 1999) have been
demonstrated using multiple baseline designs
(Gross et al., 1981;
Gross, 1982;
Gross et al., 1985) and
comparisons to psychoeducational (Kaplan
et al., 1985) and medical care alone
(Boardway et al., 1993;
Grey et al., 1999;
Gross et al., 1983).
Group-based education groups combined with instruction in relaxation and
coping with asthma also have been demonstrated more effective in improving
physical symptoms (Perrin, MacLean,
Gortmaker, & Asher, 1992;
Weingarten, Goldberg, Teperberg, Harrison,
& Oded, 1985) and behavioral functioning
(Perrin et al., 1992) when
compared to randomized no-treatment
(Perrin et al., 1992;
Weingarten et al., 1985) or
relaxation-only conditions (Weingarten et
al., 1985). Thus, coping skills groups have been
well-established for improving physical
(Gross et al., 1985;
Kaplan et al., 1985;
Weingarten et al., 1985) and
psychological (Boardway et al.,
1993; Grey et al.,
1999; Gross, 1982;
Gross et al., 1981,
1983,
1985;
Perrin et al., 1992) symptoms
because they have been demonstrated efficacious via use of multiple baseline
designs and wait-list and alternative treatment controlled comparisons.
Two sets of investigators described groups designed to provide social
support and practice of diabetes management skills. Sessions included
education about diabetes and self-management, discussion of psychosocial
issues, self-monitoring, and practice of problem solving regarding
diabetes-related situations. One intervention consisted of 18 monthly group
sessions led by interdisciplinary staff with five adolescent African American
girls (Warren-Boulton, Anderson, Schwartz,
& Drexler, 1981). Group participation was associated with
significant pre-post improvements in glycemic control and cholesterol levels.
Improved psychosocial adjustment was reported anecdotally. The other study
consisted of adolescents with diabetes in moderate to poor metabolic control
who were randomly assigned to either a wait-list or a "social support
group" that met bimonthly for 8 months
(Marrero et al., 1982). There
were pre-post trends for the group participants to have improvements on
measures of depression, self-esteem, and social support, but not blood glucose
levels. Larger sample sizes and randomized control conditions would be needed
for groups that combine education and discussion with practice of diabetes
management skills to meet Chambless/SPP criteria for being a
promising intervention for adolescents with diabetes.
In summary, multifamily groups that provide adaptation/support and skill development show positive trends for adolescents with diabetes, as well as for survivors of childhood cancer and their families. Adaptation/skill development groups that provide practice of diabetes management skills have also shown promise. However, additional studies documenting their efficacy are warranted before they can be considered promising according to Chambless/SPP criteria. Adaptation/skill development groups that target coping and disease management skills have been shown to be well-established for improving physical symptoms and psychosocial functioning among children and adolescents with diabetes and children with asthma.
Symptom Reduction Groups
Symptom reduction groups are those in which the explicit and exclusive goal
of treatment is to reduce or eliminate physical symptoms through behavior
change. Psychological or social adaptation is neither a focus nor a goal of
treatment. We identified 16 symptom reduction groups for children and
adolescents with cystic fibrosis, diabetes, encopresis, and headache. We
identified 43 articles on symptom reduction groups for pediatric obesity.
Three articles demonstrated the effectiveness of symptom reduction groups
in increasing the caloric intake and body weight of young, mildly malnourished
children with cystic fibrosis. The manualized treatment consisted of six
(Stark, Bowen, Tyc, Evans, & Passero,
1990) or seven (Stark et al.,
1993,
1996) 90-minute sessions for
patients with a collateral parent group. Both the parent and patient groups
included didactic information regarding nutrition and food preparation,
behavior management, relaxation to manage abdominal pain, and consumption of
high-caloric foods. Combined multiple baseline, changing criterion design
(Stark, Bowen, et al., 1990;
Stark et al., 1993) and a
randomized treatment with wait-list controls
(Stark et al., 1996)
demonstrated the group treatment's ability to significantly increase calorie
consumption and physical growth, with maintenance at 2 years
(Stark et al., 1993). These
group treatments meet Chambless/SPP criteria for being promising, as
there has been one study with a small sample size demonstrating the treatment
to be more effective than a wait-list control, as well as two single-case
studies conducted by the same investigative group.
Five articles described symptom reduction groups for adolescents with
diabetes. In one article (Anderson, Wolf,
Burkhart, Cornell, & Bacon, 1989), adolescents randomized to a
symptom reduction group showed improvement in blood glucose levels and
self-reported diabetes self-management when compared to standard medical care
alone. Four articles utilized group "anchored instruction" with
adolescents to improve problem solving about nutrition and social situations
affecting their diabetes care (Pichert,
Murkin, Snyder, Boswell, & Kinzer, 1993;
Pichert, Smeltzer, et al.,
1994; Pichert, Snyder, Kinzer,
& Boswell, 1994; Schlundt
et al., 1996). Anchored instruction is a technique in which a
video-presented problem serves as an "anchor" or framework for
learning. One study (Schlundt et al.,
1996) used a pre-post test design, and the other three studies
used randomized assignment to compare anchored instruction to traditional
direct instruction. Improvements were documented in diabetes knowledge
(Pichert et al., 1993;
Pichert, Smeltzer, et al.,
1994), meal planning skill
(Pichert, Smeltzer, et al.,
1994), problem solving about sick day management
(Pichert, Snyder, et al.,
1994) and managing obstacles to adherence
(Schlundt et al., 1996).
Symptom reduction groups offered via direct
(Anderson et al., 1989) or
anchored instruction meet criteria for being well-established
treatments in producing improvements in diabetes knowledge and problem
solving. Anchored instruction has been demonstrated equivalent
(Pichert, Smeltzer, et al.,
1994; Pichert, Snyder, et al.,
1994) or superior (Pichert et
al., 1993) to traditional diabetes instructions. However, symptom
reduction groups have not yet met minimum criteria as efficacious in improving
metabolic control.
We identified two studies of group treatment of encopresis using a pre-post
design (Stark, Owens-Stively, Spirito,
Lewis, & Guevremont, 1990;
Stark et al., 1997) and one
descriptive account of a 4-year-old boy with pervasive developmental disorder
progressing through an encopresis group
(Stadtler & Burke, 1998).
In the two studies (Stark, Owens-Stively,
et al., 1990; Stark et al.,
1997), children met for six 1-hour group sessions with a
collateral parent group. The parent group included information about
encopresis and its management and instruction in monitoring and behavior
management. The children's group provided a similar education component, plus
demonstration of relaxation strategies to use during enemas and goal setting
and reinforcement of fiber intake and toileting. Soiling significantly
decreased and fiber intake significantly increased from pre- to posttreatment.
These carefully conducted pre-post studies indicate that group treatment has
promise for encopresis; however, the lack of control groups prevents the group
treatment modality from being categorized as a promising intervention
according to the Chambless/SPP criteria.
Our review of the pediatric headache literature revealed four randomized
controlled studies of cognitive-behavioral training provided in symptom
reduction groups. A brief (two 90-minute sessions) cognitive-behavioral child
group with collateral parent group was no better than a wait-list control in
reducing headaches (Barry & von Baeyer,
1997). Group progressive muscle relaxation training and rapid
relaxation training were significantly better than information-only and
wait-list control conditions (Larsson
& Melin, 1986), but not more effective than individual
self-help relaxation (Larsson, Daleflod, Hakasson, & Melin, 1987) in
reducing headache frequency. Another study compared a treatment combining
headache education, group relaxation, and individual biofeedback to wait-list
and no-treatment conditions (Helm-Hylkema,
Orlebeke, Enting, Thussen, & van Ree, 1990). The treatment was
associated with a decrease in headache symptoms, but the relative effects of
the individual and group components of the treatment were not assessed. Of the
headache studies reviewed, two reported decreases in headache symptoms as a
result of group treatment when compared to controls
(Helm-Hylkema et al., 1990;
Larsson & Melin, 1986),
whereas one did not (Barry & von
Baeyer, 1997). Relaxation groups for decreasing headache symptoms
in children and adolescents meet Chambless/SPP criteria for being
promising; however, their advantage over self-managed structured
relaxation training has not been determined
(Larsson, Daleflod, et al.,
1987).
Our search yielded 33 group intervention studies using randomized treatment
designs and 7 using nonrandomized designs and targeting weight reduction in
obese children and adolescents. Because there have been recent comprehensive
reviews of treatment studies in pediatric obesity
(Epstein, Myers, Raynor, & Saelens,
1998; Haddock, Shadish,
Klesges, & Stein, 1994;
Jelalian & Saelens, 1999),
we will review the core features of the "well-established"
pediatric obesity group treatments
(Jelalian & Saelens,
1999). Interventions generally involve an initial block of 8 to 15
weekly group sessions followed by monthly follow-ups for 1 year. Sessions
include time for weight checks and reviews of diet and exercise diaries and
provide information regarding diet, exercise, and behavior modification (e.g.,
self-monitoring, parent-training, contingency management and contracting,
problem solving, and goal setting) (e.g.,
Epstein, Wing, Koeske, & Valoski,
1984). Data include patients' weight, body mass index, nutritional
and caloric intake, and activity and fitness levels. Most studies document
weight reductions of approximately 5% to 20% in percent overweight immediately
following treatment (Jelalian &
Saelens, 1999). Follow-up assessments have been conducted to 10
years (e.g., Epstein, McKenzie, Valoski,
Klein, & Wing, 1994). Across studies, the most durable
outcomes appear to be achieved with collateral parent and child groups in
which both parent and child weight loss is targeted
(Epstein et al., 1994) and
where lifestyle changes in activity and exercise are targeted
(Epstein, Wing, Koeske, & Valoski,
1985). Researchers also have examined effects of treatment/weight
loss on psychopathology and self-esteem, with equivocal findings
(Foster, Wadden, & Brownell,
1985; Myers, Raynor, &
Epstein, 1998; Sherman,
Alexander, Gomez, Kim, & Marole, 1992). Based on the existence
of numerous well-controlled, randomized studies from different investigators,
group treatments for pediatric obesity are well-established; however,
their superiority to individually based treatments has not been thoroughly
investigated (Braet, Van Winckel, &
Van Leeuwen, 1997).
The literature on symptom reduction groups is relatively rigorous in terms of both outcome measurement and experimental design. Although the number of studies and sample sizes vary by disease, considered together as an intervention format, symptom reduction groups can be considered a well-established treatment for improving pediatric patient knowledge, disease management, and problem-solving skills, as well as physical symptoms.
Summer Camps
Summer camps are residential or day programs designed for children with
chronic illness or disability, which include typical social-recreational
activities such as crafts, swimming, and campfires. Unlike other forms of
groups, they may or may not include didactic activities or discussions focused
explicitly on illness-related issues. We identified 23 articles describing
summer camp interventions offered for children with asthma, cancer, diabetes,
HIV infection, obesity, renal disease, and spina bifida. Adaptation to illness
was the primary target of the majority of these camp programs, although some
camps for children with diabetes and asthma also targeted symptom
reduction.
Of those camps targeting adaptation primarily, program evaluation methods
ranged from qualitative data on parent consumer satisfaction to standardized
measures of attitudes and psychological symptoms. Qualitative evaluations of
the impact of camp on parent or child attitudes about the camp experience were
positive for campers with asthma (Silvers
et al., 1992) and cancer
(Bluebond-Langner, Perkel, & Goertzel,
1991; Hvizdala, Miale, &
Barnard, 1978). Pre-post evaluations without control groups of
camps for children with cancer found increased knowledge of cancer
(Bluebond-Langner, Perkel, Goertzel,
Nelson, & McGeary, 1990), equivocal findings regarding
self-concept (Benson, 1987;
Eng & Davies, 1991), and
improvements in campers' social and physical activity after camp and family
members' social activities during and after camp
(Smith, Gotlieb, Gurwitch, & Blotcky,
1987). Evaluation of a camp for patients with renal failure
indicated improvements in depressive symptoms, hopelessness, and
self-efficacy, but sample size was small, no control group was employed, and
statistical information was not provided
(Warady, Carr, Hellerstein, & Alon,
1992). A study assessing the impact of camp on children with spina
bifida, asthma, and diabetes who went to camp at separate times found
statistically significant overall improvements in standardized measures of
anxiety and attitude (Briery & Rabian,
1999). However, only children in the asthma and diabetes groups
showed decreases in anxiety over the course of camp.
Camps for children with diabetes and asthma were more likely to use
standardized evaluation procedures and to target self-management and symptom
control in addition to adaptation to the illness, with mixed results. A
pre-post evaluation of a 1-day camp attended by urban African American
children showed better self-management and fewer complications of asthma
(Fitzpatrick, Coughlin, & Chamberlain,
1992). When compared with control conditions, camps for children
with asthma have shown equivocal results. A camp incorporating yoga with
psychotherapy was associated with improvements in asthma symptoms in older
adolescents (Vijayalakshmi, Satyanarayana,
Krishna, & Prakash, 1988), but a camp for younger children
(7-15 years) yielded no differences between campers and controls in asthma
symptoms, knowledge, or attitudes (Hazzard
& Angert, 1986). A study comparing asthma camp with inpatient
hospitalization showed the inpatient program to be more effective but was
fraught with confounds (e.g., setting and duration) and lack of random
assignment (Brazil, McLean, Abbey, &
Musselman, 1997). No controlled studies of camps for children with
diabetes were identified. However, pre-post evaluations have shown increases
in knowledge and self-management during camp
(Havarky et al., 1983;
Spevack, Johnson, Riley, &
Silverstein, 1991), with maintenance of behavioral changes
moderated by family functioning (Holden et
al., 1991).
A summer day camp in Thailand targeted obesity in children via daily
dietary restriction, nutrition education, exercise, and individual and group
therapy (Jirapinyo et al.,
1995). Over a 4-week period, participants lost an average of 5% of
initial weight and a statistically significant amount of body fat. An earlier
article described a summer camp for boys with obesity that resulted in a
statistically significant improvement in the trend of weight gain for
participants (Rohrbacher,
1973). No control groups were employed.
In summary, pre-post evaluations have indicated that campers gain
disease-related knowledge and may have improvements in self-esteem, anxiety,
attitudes toward the illness, and management of asthma, diabetes, and obesity.
However, gender (Punnett & Thurber,
1993), age, family functioning, and experience with camp may
moderate treatment effects, and the generalization of treatment effects once
camp has ended has been questioned. Because controlled comparisons have rarely
been reported, summer camp interventions do not meet minimum Chambless/SPP
criteria for empirical validation.
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Discussion |
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TopAbstractIntroductionLiterature SearchMethodological CriteriaResultsDiscussionAppendixReferences |
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Our review found that group interventions have been used with a variety of pediatric populations to increase knowledge of the medical condition, increase adaptation to the illness, and reduce physical symptoms. The studies fell on a wide continuum of empirical sophistication from descriptive articles with no empirical assessment of outcome to treatment outcome studies employing randomized control conditions and standardized outcome measures.
There have been no well-controlled studies of emotional support groups, although there were instances in which standardized outcome measures were used to assess pre-post changes. Likewise, systematic evaluation of psycheducational groups was rare and used pre-post designs and a mix of standardized and nonstandardized outcome measures. When randomization did occur, the psychoeducational group was considered the control condition and was compared to an active treatment condition. For emotional support and psychoeducational groups to meet criteria for being promising interventions, they need to be compared to randomized wait-list control conditions with standardized measures.
Adaptation/skill development groups have been evaluated more rigorously with several instances of randomized trials and use of standardized measures. Results supported this modality as a well-established intervention for physical symptoms and a probably efficacious treatment for psychosocial outcomes among children with diabetes and asthma when coping skills are taught. Whereas groups that target diabetes management skills and multifamily groups that target family communication and conflict have some support in the literature, additional evidence from well-controlled studies is needed for them to meet minimum Chambless/SPP criteria for efficacy. In the studies reviewed, symptom reduction groups were evaluated with the most sophisticated methodology. Efficacy has been demonstrated from the level of a promising intervention (e.g., relaxation groups for headache) to a well-established treatment (e.g., pediatric obesity groups). Although positive pre-post effects have been found for camp interventions, they have not been compared to a randomized control condition; thus, efficacy has not been established.
We frequently encountered a mismatch between the stated target of group interventions and the outcome measures employed. As an example, emotional support groups aim to increase perceived social support and decrease isolation. However, treatment adherence or symptom control was a measured outcome in some studies we reviewed. Similarly, studies investigating interventions with the dual goals of enhancing adaptation and reducing symptoms did not always include measures of both psychosocial and physical outcomes. Improving the correspondence between treatment objectives and their measurement will significantly advance evaluation of the efficacy of group treatments.
This review highlighted the stages through which interventions are tested.
We hope that researchers interested in group treatment evaluation can use this
review to bring the literature to the next stage in efficacy evaluation. For
example, if an intervention is untested, practitioners may consider adding a
pre-post objective measure of expected treatment effects, or if resources are
few, an easily administered evaluation of consumer satisfaction and perception
of change. Whereas consumer satisfaction generally cannot be used as a proxy
for change in symptom level (Lambert,
Salzer, & Bickman, 1998), it is an important first step in
determining feasibility for new treatments
(Bauman, Drotar, Leventhal, Perrin, &
Pless, 1997) and is considered an important outcome by managed
care organizations (Lambert et al.,
1998). If the most empirically sophisticated studies on a group
intervention used nonrandomized designs and nonstandardized measures, then
randomized control trials with standardized outcome measures would bring that
intervention to the next step in evaluation. Finally, all modalities require
research on pediatric populations for which the treatment has not yet been
shown to be efficacious.
We have no doubt that there is a significant gap between what is clinically
available and what has been empirically validated. For example, although we
found no articles describing or validating groups that target pain management
for children or adolescents with sickle cell disease, we are aware of such
groups offered routinely at pediatric hospitals. Furthermore, many of the
studies we reviewed were grant-funded, recruited extensively for treatment
groups, or had many exclusionary criteria for participation, which limit the
external validity of their findings. Studies showing efficacy under these
conditions must be followed by effectiveness studies, documenting levels of
efficacy under typical clinical conditions
(Kazdin & Weisz, 1998;
Weisz, Weiss, & Donenberg,
1992).
As evidence for the efficacy of group treatment is gathered, a question
arises regarding the relative efficacy and cost-effectiveness of group versus
individual treatment, since some individual treatment interventions have been
empirically validated for reducing disease-related symptoms in children
(McQuaid & Nassau, 1999).
Although some of the individual studies have been methodologically flawed,
reviews and meta-analyses comparing individual and group psychotherapy for
child clinical populations have not found statistically significant
differences between the modalities (Hoag
& Burlingame, 1997); however, the empirical pediatric
literature has addressed this question only in a few instances
(Braet et al., 1997;
Larsson, Daleflod, et al.,
1987). It is important to investigate how efficacy might differ
across illnesses or within the same illness population by age/developmental
level, gender, race, ethnicity, and family and psychosocial factors.
Group treatment is often discussed as a cost-effective alternative to
individual treatment. However, the articles we reviewed suggested higher
setting, material, and staffing costs. Most of the empirical, structured
groups were externally funded. Participants were reimbursed for their
participation and, in some cases, for reaching treatment goals (e.g.,
Epstein, McKenzie, Valoski, Klein, &
Wing, 1994). Among programs within existing clinical services
(e.g., Stark, Owens-Stively, et al.,
1990), treatments were provided on a fee-for-service basis, which
requires additional time for clinical record-keeping. Many of the studies we
reviewed referred to the cost-effectiveness of the group interventions they
were investigating, but only two (Larsson,
Daleflod, et al., 1987;
Warren-Boulton et al., 1981)
made any attempt to estimate the cost savings of their intervention. More
attention to this variable is necessary to justify the use of a group modality
in circumstances in which it is found to be no more effective than individual
therapy.
It has yet to be demonstrated that forming homogeneous groups is necessary
for effectiveness of any or all types of treatment groups (educational,
adaptational, etc.). When forming groups, the more empirically oriented
treatments employed inclusion and exclusion criteria in consideration of the
developmental characteristics of the participants (e.g.,
Epstein et al., 1998), their
race (e.g., Ceccoli, 1992;
Wadden et al., 1990), and
their severity or stage of illness or treatment (e.g.,
Grey et al., 1999;
Kazak et al., 1999). Although
we assume that compatibility may enhance group process, overfocusing on the
homogeneity of groups may critically reduce the number of eligible
participants and may exclude participation of underrepresented populations.
Most of the reviewed studies described groups targeted to one particular
medical condition. For pediatric conditions of relatively low incidence, there
simply may not be enough children who share the same diagnosis or treatment
goal to allow group treatment. Multisite studies may be used to garner large
enough sample sizes to evaluate treatment efficacy of groups.
Although many issues in need of study have been raised, research on group interventions for each individual pediatric condition must begin where previous investigators ended. Again, we hope that this review can serve as a guide, both for the practitioner seeking to implement the current "state-of-the-art" group intervention and for the researcher planning to take the next logical step in evaluating group treatment for a given pediatric condition.
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Appendix |
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TopAbstractIntroductionLiterature SearchMethodological CriteriaResultsDiscussionAppendixReferences |
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Articles Reviewed, Categorized by Illness Type
Key:
- ES = Emotional Support
- P = Psychoeducation
- A/SD = Adaptation/Skill Development
- SR = Symptom Reduction
- SC = Summer Camp,
,
,
,
,
,
,
,
,
,
,
,
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|
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Notes |
|---|
Romy Engel is now at the New York University Child Study Center.
Received July 31, 2000; revision received December 13, 2000; accepted February 7, 2001
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References |
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TopAbstractIntroductionLiterature SearchMethodological CriteriaResultsDiscussionAppendixReferences |
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