problem-solving approach suggests modest benefits on very discrete areas of social functioning that appear to have some durability.

Although such research seems old-fashioned and potentially out of sync with the dilemmas and challenges facing an adolescent suffering from schizophrenia, the approach may have merits. For a child, the transition into adolescence and then adulthood is a difficult process requiring support and structure. Development of schizophrenia during this process can disrupt personal development in an infinite number of ways. Therefore, there is a real need for research among groups of adolescents with schizophrenia into developing ways to teach them social skills that generalize to real life.

Successful family therapies have psychoeducation at their heart, taking the form of a collaborative respectful relationship with the family, provision of information, and teaching of family members less stressful ways of communicating and solving problems. It seems intuitive that family interventions, in a nonspecific sense, would be particularly beneficial for adolescents with schizophrenia, especially those who remain still dependent on their parents.

The need for intervention is supported by reports that children with schizotypal personality disorder or schizophrenia and the parents of such children tend to show increased rates of thought disorder during direct family interactions (Tompson, Asarnow, Hamilton, Newell, & Goldstein, 1997). Some reports claim that the parents also show increased communication deviance (an index of difficulties associated with a failure to establish and maintain a shared focus of attention; Asarnow, 1994). It is not possible to know at this stage whether this represents a shared genetic vulnerability to psychosis or a parental response to their child's illness.

Additional support comes from the work on expressed emotion (EE). Although this was originally investigated in adult populations, most data assessing family interventions in adolescents are based on EE. The concept of EE, which encompasses critical comments, hostility, and overinvolvement, arose out of a body of research focused on the effect of the family environment on the maintenance of schizophrenia and other severe mental disorders (Brown, Monck, Carstairs, & Wing, 1962). Family interventions evolved, again targeted at adults, that aimed to reduce high EE and thus reduce relapse rates (Leff, Kuipers, Berkowitz, Eberlein-Vries, & Sturgeon, 1982).

Compliance therapy is a brief, pragmatic intervention in which cognitive behavioral techniques, very closely linked with motivational interviewing, are used to focus on improving treatment adherence. This therapy evolved out of initial work in programs using psychoeducational and behavioral techniques (e.g., Eckman et al., 1992), and its further development was encouraged by the UK National Health Service, which declared noncompliance a research priority. It was tested in a pilot study, modified, and then used by Kemp, Hayward, Applewhaite, Everitt, and David (1996) in an RCT of inpatients with psychotic illnesses with follow-up to six months. Eighteen-month follow-up was reported (Kemp, Kirov, Everitt, Hayward, & David, 1998) using an expanded sample. The therapy itself takes place over four to six sessions of 20 to 60 minutes each, approximately biweekly and involves the following:

Despite the fact that the therapy was biased to encourage only positive attitudes to treatment, the therapy also aimed to reframe the use of medication as a decision, freely chosen to enhance quality of life, referred to as an “insurance policy” or “protective layer.” Immediately after the intervention, the compliance therapy had significantly improved insight and compliance, compared to a supportive counseling matched for therapist time, with the same therapists. This effect was maintained at 6-month follow-up with a 23% difference between groups, with those with higher IQ achieving better results. It was not possible to determine whether these gains resulted in increased function or diminished relapse rate. The 18-month follow-up confirmed that compared to the control condition, compliance therapy improved compliance and insight in the intervention group by 19% and improved global functioning, especially as time progressed. It had no overall effect on improving symptomatology or reducing time spent in the hospital over the follow-up period. The positive effects on compliance were not replicated by O'Donnell et al. (2003) in an RCT of adult inpatients with schizophrenia. Compliance therapy, administered according to Kemp et al. (1996, 1998), conferred no advantage in compliance, symptomatology, or overall function outcomes at 1 year post-therapy, compared to a control condition of equivalent duration with nonspecific counseling. Furthermore, one struggles to see how such a therapy could exert such a persuasive effect in a teenager in the throes of puberty and a battle for independence. Yet again, there is a real need for adaptation of such techniques to adolescent populations, followed by RCTs evaluating their effect.

Although many illicit substances are used by individuals with psychosis, our discussion of such

substances will be limited to cannabis because it is by far the most common illicit substance used by adolescents.

Studies attempting to assess efficacy of psychological treatments have been hampered by a multitude of methodological problems. Often very different versions of a treatment model are described as one and the same. They are often applied to heterogenous populations (e.g., different ages or illness stages) and compared with a control condition unmatched for therapist time and attention.

Debate also continues about the best way to assess the outcome of such interventions. Bellack and Brown (2001) feel that judging psychosocial treatments on the same outcome measures as pharmacological intervention might not be appropriate. Rather than evaluating therapies on whether they reduce symptoms, induce remission, or prevent relapse, they recommend focusing on their effect in reducing impairments in social role functioning and improving overall quality of life and treatment adherence. So they recommend rehabilitation rather than treatment, taking into account the confounding effect of cognitive deficits and the need for newly learned skills to generalize to real life in the community. They liken psychosocial therapies to the use of Braille in visually impaired individuals.

Outcome studies in schizophrenia tend to focus on categorical measures, such as hospital admission, and on professional observations of relapse, symptomatology, or cognitive impairment. Very few assess psychosocial outcome or quality of life, especially as rated by users of services and their caregivers. Such measures of outcome are particularly important for adolescent populations. Lay, Blanz, Hartmann, and Schmidt (2000) conducted a 12-year follow-up study of 96 consecutively admitted individuals with schizophrenia (aged 11 to 17). Of the 68% reassessed at 12 years, 66% had serious social disability, which was predicted by severity of positive symptoms in the early stages and by admissions numbering more than two; 75% were financially dependent. Jarbin, Yngve, & Von Knorring (2003) conducted a 10-year follow-up of adolescents (age <19 years) who were diagnosed with first-episode early-onset psychosis in the 1980s and early 1990s; 79% of those with early-onset schizophrenia spectrum disorders suffered a chronic course with poor outcome.

The collaborative and empowering nature of many of the psychotherapeutic options, though incompletely evaluated and not always available, switches our focus from such sobering outcomes and inflicted choices to a more patient-driven framework. It is encouraging to see that the quest for alternatives and adjuncts to pharmacological treatments has been stepped up and that attempts are being made to improve the methodological quality of their evaluation.

However, a clinician faced with an adolescent newly diagnosed as having schizophrenia would find it extremely difficult to tease out which interventions might be helpful and of these, which might be a cost-effective use of available resources. Adolescents continue, as before, to fall between child and adult services in terms of service provision (National Institute of Clinical Excellence [NICE], 2002). Perhaps mental health initiatives, building on the continuing outcomes of early-intervention programs, can shape devoted services to be targeted at problems that beset adolescents with schizophrenia by virtue of their developmental stage. Such initiatives need to be designed specifically for young minds and hearts.