a comparison of individual and family approaches to initial assessment

European Child and Adolescent Psychiatry, Vol. 4, Issue 2, April 1995, pp. 94-101 �9 Hogrefe & Huber Publishers

A Comparison of Individual and Family Approaches to Initial Assessment

Antony Cox*, Rosemary Hemsley** and Jonathan Dare***

The study aimed to examine the influence of initial mode of assessment on attendance, and later assessment and treatment. 100 children newly referred to a child mental health service were randomly assigned to (i) initial family assessment; child and family seen together, or (ii) individual assessment, child and parents seen in parallel. Those invited were more likely to attend following "individual" appointment letters because parents did not always bring all the children in response to "family" appointment letters. Failure to attend the second appointment occurred twice as often if there was a change in who was asked to attend. Psychometric assessment was more often requested following an initial family interview. Long term mode of therapy appeared to be partly but not wholly influenced by initial assessment method. Results suggest that sustained co-operation with long term therapy is more likely to occur when clinicians vary the family members they are working with according to the needs of the case.

Keywords: Interviewing, Family, Assessment, Child

Introduction

Family therapy has become an established mode o f t reatment in child psychiatry. However , family meetings are not the optimal intervention method in all cases (Cox, 1994). So the question arises as to what methods o f assessment should be used at first contact with a family o f a referred child.

A family perspective is always relevant in assessment, but i f the treatment team wishes to keep its options open, should the aim be to see the whole family at first contact, or only the parents and index child? It is o f course possible to conduct individual interviews with parents and child and an extended assessment o f the whole fam~y on the same occasion but it is cumbersome and not likely to be well tolerated by many families. I f a decision is taken to do individual or family assessments on other oc- casions, does it matter which is done first? For example, is attendance at first interview affected by whether parents are asked to bring all those living at home or only the referred child? Does the mode

o f the first assessment interview affect attendance at the second? Does it influence what further investigations are sought? Is psychometric assessment requested more often when the referred child has been seen alone at first contact with the clinic? If the assessing teams start in one mode, are they likely to forego assessment in the other mode, so that the initial assessment approach becomes the treatment approach? If there is a decision to change the mode o f contact from that used for the initial assessment, does that affect the family's attendance at the next interview, and subsequent treatment?

It has been shown that preparation facilitates attendance for initial assessment at child mental health services (Churven, 1978; Kourany, 1990) and a comparison o f initial family and individual interviews indicates that the information obtained can be in some respects different (Eminson, 1988). Another study has examined dropout at various points o f the assessment and treatment process (Cottrell et al., 1988). However , these studies were not directly concerned with the advantages and disadvantages o f initial individual and family

' / t

9 r

Department of Child Psychiatry, UMDS, Guy's Hospital, London SE1 9RT, UK Department of Psychology, Institute of Psychiatry, London SE5 8AF Belgrave Department of Child & Family Psychiatry, King's College Hospital, London SE5 9RS Received: 29 March, 1994 Accepted for publication: 26 October, 1994

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modes o f assessment with regard to future collaboration with assessment and treatment.

The present project aimed to study whether initial modes o f assessment, child and parent(s) separately versus family seen together, influenced engagement, further assessment or mode of treatment. Subsidiary goals were to examine whether initial appointment letters inviting families as opposed to index child and parents affected who attended and what treatment method was employed in the longer term.

The project was conducted by a child mental health service that had been recently established in a new community medical centre. Staffcomprised child and adolescent psychiatrists, educational and clinical psychologists, social workers and child psychotherapists. All were expected to participate in both modes o f initial assessment. This particular child mental health service has a major training role for psychiatrists, psychologists and social workers and is situated on a relatively new but al- ready vandalised housing estate in an economically depressed inner city area o f London. There are high rates o f unemployed and single parents amongst families referred to the clinic. If there are breadwinners, they are usually in unskilled or semi-skilled manual jobs. It was considered ad- visable to keep initial assessments to less than two hours duration if co-operation was to be sustained.

Method

The essential design of the study was to assign new referrals to the child mental health service alter- nately to an initial family assessment or an assessment in which the referred child was seen separately from parent or parents. Records were kept of initial attendance, subsequent further assessments and mode of treatment in the immediate and long term. Drop out was recorded whenever it occurred and defined as failure to return before the therapist and family had decided jointly to ter- minate contact.

The sample consisted o f 100 consecutive referrals to the service. A small number o f cases were not processed as part o f the study: emergencies, children referred for court reports and re-referrals were all excluded. All other cases were assigned to predesignated pairs o f staff, who alternated between initial family and individual mode of assessment with successive cases. Pairs ofstaffalways in-

cluded two people o f different disciplines. Trainees were paired with an experienced staff member. The members o f each pair saw families conjoin@ in the family condition and alternated whether they saw the parent(s) or child in the individual assessment mode. This meant that all staffmembers o f whatever discipline had to be prepared to fulfil any role. When additional assessments, such as physical or psychological assessment were considered crucial, they were arranged on a separate occasion. These were performed by someone o f the appropriate discipline - bringing in another staff member if necessary.

An individual interview meant the child was seen on his/her own for a period o f 30-60 minutes by one staffmember while the other met with parent(s) on their own for an interview not exceeding 75 minutes. In the family assessment, therapists acted conjointly for a session not exceeding 90 minutes. If the cases were seen as part o f a formal teaching occasion, other staff members observed the interview through a one-way screen, provided that the family gave permission. In individual interviews, the staffmember observed was alternated as only one observation room was available.

Following assessment interviews, there was a break of fifteen minutes for assigned staffto discuss further action. If there were observing staff, these were included in the discussion. Family members were then seen again by the assigned staffto discuss the initial formulation o f the problem and plans for the next contact. Normally all the family were seen together at this point, irrespective o f whether the initial assessment had been in Individual or Family mode. After this, a member o f the clinic staff not assigned to the case asked each member o f the family to fill in a questionnaire. This included open questions concerning feelings about the visit, difficulties attending and criticisms o f clinic function. On a series o f five point scales family members rated how well they had been able to explain the problems that concerned them, staff understanding of the problems, whether the visit had altered perception of the problem or feelings about it and whether it had been helpful. Family members were also asked how they felt about being observed and whether they would have liked to talk to the staffmembers alone or with the whole family, depending on how they had actually been seen.

Subsequently, the assigned staff were free to continue contact with the family in any mode that they considered clinically appropriate. The full

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range o f physical and psychological investigations and therapeutic techniques were available, including behaviour modification and drug treatments. Records were kept o f the style o f the second contact and mode o f long term treatment, as well as any special investigations undertaken. Each case was reviewed by the researchers either when it was closed or at a stage when investigations were com- plete and long term treatment established.

Assessment o f statistical significance was by Chi- square test, wi th the Yates correct ion, except where Fisher 's exact test was used when small numbers were involved. T-tests were used to com- pare age differences between groups.

Results

Response to the Initial Appointment Letter

a) Attendance

Fifty-five families received an initial letter requesting attendance o f all those in the household (the family condition) and 45 a letter requesting attendance o f the index child and parent(s). Assignation o f cases to pairs o f staff was dependent on staff availability so that strict alternation o f assessment mode for each pair led to some inequality in the groups receiving Individual and Family letters. The two groups did not differ significantly with respect to the ages of the index children and their sex. There were somewhat more one-parent famihes assigned to the Individual condit ion but not significantly more (Table 1).

The proport ion o f families cancelling the first appoin tment or failing to attend was similar in those sent a Family letter and those sent an Indi- vidual letter. In a proport ion o f cases who cancelled or failed, further appointments were sent. These further attempts were successful to a similar extent in both groups, so that the overall success in achieving at least some attendance at the first interview was almost identical with the two different letters (Family 69.1%, versus Individual 73.3%). The index child was younger where there was failure to attend following a Family letter as opposed to an Individual letter, but not significantly so. Six families phoned to cancel the first appointment and 5 of these came to the next appointment offered, but o f the ten who failed and did not cancel only one attended when offered another date. (Fisher's Exact p = .0075).

Table 1. Initial letter.

Family Indi~du~

n 55 45 Referred child male 36 (65.5%) 29 (64.4%) Mean age 9y8 m 10y9 m of child (SD) (SD 3yl I m) (SD 3y9 m) Single parent family 14 (25.5%) 18 (40%) Failed/cancelled first appointment 21 (38.2%) 14 (31.1%) Further appointment sent 12 4 Failed/cancelled further appointment 8 (66.7%) 2 (50.0%) Total number with some attendance 38 (69.1%) 33 (73.3%) at first interview Mean age non- 8ygm 1 ly9 m attenders (SD) (SD 3yll m) (SD 3yl m)

all differences non-significant

b) Persons Attending the First Interview

Although the two letters were equally successful in gaining at least some attendance at the first interview, the Individual letter more often produced attendance of those invited ie. parent(s) and index child (Family 34.5% versus Individual 55.6%: ldf p < 05). However, attendance o f the index child and the parent(s) was equally successful with either letter (Family 52.7% versus Individual 55.6%: ldf, n.s.). The difference in success wi th respect to prescribed attendance was entirely accounted for by families in the Family condit ion who did not bring all other children in addition to the index child (20%). However, three mothers failed to attend following a Family letter. In two families (one Family and one Individual) there was no mother and neither family even attended. Whether there was a father as well as a mother in the household, did not affect attendance since the proport ion of families with a father in the household was similar for attenders and non-attenders (69% vs 72.4%).

Amongst attending families, 49 had fathers in the household and 38 (77.6%) attended the first contact. A further four fathers later attended so that contact was eventually made with 42 (85.7%) of the fathers.

Response to the Initial Assessment Interview

In 8 cases, the style of the initial assessment was changed. Five families receiving Individual letters were seen as families - twice because the paired staff member was ill and three times because the child would not separate. Three families receiving

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Family letters were seen individually. O n two oc- casions parents arrived without the child and once only the mother and child arrived and they were seen separately. This meant that 40 families had an initial family interview and for 31 the index child and parent(s) were seen separately.

Twenty-eight interviews (14 Family and 14 In- dividual) were observed and 43 were not (26 Fam- ~y and 17 Individual).

Did the mode o f initial assessment affect subsequent attendance? One family who received an individual assessment was not given a further appointment. In the remainder, the proport ion attending at the second clinic contact was almost identical in the two groups (Table 2).

Table 2. Mode of initial assessment.

Family Individual n 40 31

No further appointment - 1 Not attending next appointment 10 (25.0%) 8 (26.7%) Boys not attending 9/29 (31.0%) 3/19 (15.8%) Girls not attending 1/10 (10.0~ 5/10 (50.0%) Contact re-established by home visit 4 1 Never re-attended 4 (40.0%) 5 (62.5%)

Attendance and observation of initial assessment Observed Not observed (n = 28) (n = 43)

Not attending next appointment 8 (28.6%) 10 (23.3%)


The therapist(s) re-established contact by home visit in more o f the ~milies having an initial family assessment, but there was no significant difference in the proport ion who never re-attended in the two groups. Index children were usually, but not always, expected to attend the next appointment. Amongst those who were, there was a suggestion of a sex difference, such that non-attendance o f boys was more c o m m o n after initial family assessment, o f girls after an initial individual assessment. However, these differences were not statistically significant. In all but two instances, non attendance meant non-at tendance ofaU family members. O b - servation o f the initial assessment was not associated with a difference in subsequent attendance.

Cbcmge in Mode of Contact

If the assigned staff proposed a different mode o f contact after the first interview, did this influence compliance? Non-at tendance at the next appointment occurred twice as often if staff proposed a different mode (35.5% vs 17.9%: df l , n,s.) (Tab. 3).

Table 3. Attendance and proposed mode of next contact.

Proposed mode of next contact Same as first Different from (n = 39) first (n = 31)

Percentage not attending second appointment 17.9% 35.5%

Mode of initial assessment Family Individual

n 40 30

Proposed mode Attendance Attendance of next contact rate% rate%

Same as first 19 (47.5%) 78.9 20 (66.7%) 85.0 Parents only 8 (20.0%) 87.5 4 (13.3%) 50.0 Opposite to first 13 (32.5%) 61.5 6 (20.0%) 50.0 % Attending as intended 70% 66.7%


Failure to attend was somewhat more frequent i f a change was proposed following an individual initial assessment (Family 28.6% vs Individual 50%: ldf, n.s.). In particular, requests for the parent(s) to attend without the children appeared more successful following an initial family assessment (Fam- ily 87.5% vs Individual 50%: ldf, n.s.). However , even if there was attendance, it was not always ex- actly as proposed. Looked at in this way, similar proport ions at tended at the next contact as intended, whatever the initial mode o f contact (Family 70% vs Individual 66:7% 1dr, n.s.).

Psychometric Assessment

The commonest special investigation requested was psychometric assessment o f the index child. The resources o f the clinic did not permit routine assessment, so that selection had to be made. Ex- cluding those assessed before first at tendance, psychometric assessment was requested more fre- quently when initial mode o f contact was with the whole family (Table 4).

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Table 4. Psychometric assessment.

Mode of initial assessment Family Individual

n 40 31

Assessed prior to referral 10 (25.0%) 7 (22.3%) Not psychometrically assessed at any stage 16 20 Assessed after attending 14 4 Comparison of family and individual assessed a~er attending: Z2 = 4.13; dfl; p < 0.5

Long Term Therapy Style

M o d e o f initial assessment did not influence whether long term therapy (more than four ses- sions) took place (Initial family assessment 80% vs Individual 77.4%). Staff were more likely to engage solely in long term therapy in the individual mode i f they had started in that mode - although not significantly more often. They were also more likely to include at least some family work i f there had been a family assessment (Initial family 59.3% vs Individual 37.5%). It is notable that it was not uncommon for long term therapy to use both individual and family modes o f intervention (Table 5).

Table 5. Long term therapy style.

Mode of initial assessment Long term style Family Individual n 40 31

No long term therapy 8 7 Same as initial 12 (37.5%) 15 (62.5%) assessment Different from initial 13 (62.5%)* 5 (37.5%)* assessment Mixed family and 7 4 individual approach Same vs other X 2 = 2.5; dfl; n.s.

* percentage of long term therapy, including at least some work with an approach different from the mode of initial assessment.

Ultimately, 28 cases were engaged in long term individual work, 17 in family work and in 11 cases the approach was mixed. This means that some individual work was more common amongst cases in long term therapy.

Families' V iews

After the first assessment interview, an independ- ent staff member asked all the family members present to fill in a questionnaire which comprised some open questions, e. g., "What was your overall feeling about the visit today?" and some questions requiring a rating on a five point scale, e. g., "Were you able to explain the problems that concern you?" Eleven families who attended the first appointment were not given questionnaires (8 seen as a family and three individually) and o f families who did not attend the first appointment but came later, three o f the 7 were not given a questionnaire (two seen as a family and one individually). Since 29 never attended, questionnaires were available for 57 families, 30 seen in the family mode and 27 individually. Because questionnaires were most consistently obtained for the mother and index child, only their questionnaires were analysed.

Analysis focused on responses to the different style o f assessment and subsequent attendance. In the case of the mothers, there were no significant differences according to family or individual initial assessment. Mothers were equally likely to rate favourably or unfavourably in answer to the questions about how well they could explain their problem, how well the staff had understood the problem, any change in their feelings about the problem and whether they had found the visit helpful. However , they were more likely to attend the next interview if they rated themselves less worried about the problem at the end of the first session (Table 6).

Table 6. Attendance at next interview.

Mother's view of the presenting problem (after first interview) Yes No

More worried about problem 19 14 Less worried about problem 21 3

~2 = 4.6; dE.l; p < 0.5

In individual as opposed to family assessment, the children rated themselves as more able to explain the problem that concerned them, at least quite well (22.2% vs 81.8%, df 1, X2 7.5 p < .01). They were also more likely to rate the visit as more helpful i f the mode was individual but this was not significant (58.5% vs 77.8%). In the individual mode, seven of nine children rated the visit quite or very helpful.

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Ifa comparison is made of how the index child and their mothers rated in answer to all rated questions, then children were more likely to rate dif- ferently from their mothers in the family mode (Table 7).

Table 7. Rated responses to questionnaires.

Index child's rating Assessment Same as Different

mother's

Family 51 56

Individual 39 20

~2 = 4.49; dfl;p < .05

The child rated worse than their mother after the family assessment especially in response to the question "Were you able to explain the problems that concern you?". (~2 6.97, dr1, p < .02) and "Did the staffunderstand the problems?" - this latter was not significant. In contrast, after family assessment six children rated more favourably than their mothers in answer to the question "Was the visit helpful?" - all rated in the same way as their mothers after individual assessment.

Discussion

The project makes clear that random allocation o f assessment procedures can be achieved in a busy inner-city child mental health service. The relative imbalance o f numbers assigned to receive the two different types o f initial letter was a consequence of the random procedure. A few cases were assessed in a fashion contrary to the initial letter. Where this was due to staffsickness, the allocation could still be considered random, but this was not so for the three cases where the child would not separate, nor for the two where the staff decided to see the mother and child separately when they came without the father. However apart from these two latter cases, the staffcan be said to have complied with randomisation.

There was a lesser degree o f success in getting post-interview questionnaires fi:om family members - in 14 o f 71 attending families, they were not given. The administration depended on the availability o fa staffmember not directly involved with the case. This was not always possible to ar-

range. The relatively small size o f the sample meant that although there are many clearly negative findings, there are a number o f results which are in- conclusive and would merit further investigation.

Twenty-nine per cent o f families never attended, a much higher rate than that reported by Eminson at a United Kingdom adolescent psych!a- ttic out-patients clinic (Eminson, 1986) and by Cottrell et al. at a teaching hospital department o f child psychiatry (Cottrell et al., 1988) but similar to that in an American child study centre (Shapiro & Budman, 1973). This may have reflected inap- propriate referral or inadequate preparation o f referrals. The clinic was newly opened and meetings had taken place with a number o f potential referral agents. Nevertheless, there were sources o f referral who were not adequately preparing families to attend. On the other hand, the adolescent clinic reported by Eminson may have been seeing cases thought more severe by both the family and the referrer so that there was better preparation. The proportion in long term treatment was similar in both the teaching hospital department (Cottrell et al., 1988) and the communi ty child mental health service reported here. This supports the no- tion that the lower rate of initial attendance in the community clinic reflected poorer preparation by the referrer.

The results indicated that Individual and Family letters were equally good at getting attendance o f parents and index child but that other family members requested to attend for family assessment did not always do so. Whether parents bring all family members when invited may therefore reflect their views about their inclusion. Churven (1978) has shown that preparatory direct contact can help families to see the appropriateness o f whole family attendance. The majority o f fathers came to the initial assessment in the present study when requested to do so (78%). Appointment letter included a phrase emphasising the impor- tance o f fathers' attendance. It may be that the insertion o f a phrase emphasising that brothers and sisters would be welcome would have led to greater attendance o f other children. There is reported to be a higher chance o f families' con- tinuing in treatment when the father attends the first session (Heubeck et al., 1986), so it is clearly worth while to take action that increases the chance o f fathers being involved. The study did not address the appropriateness o f initial family or individual assessment to the nature o f the reported problem. Elsewhere it has been argued that there

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needs to be flexibility in choice and ordering o f assessment approaches according to, for example, the age o f the child or adolescent and the type o f problem. Discussion with the adolescent on their own may be important for later co-operation, and, where individual assessment is crucial to diagnosis, as in autism, depression in adolescence and psychosis, there needs to be a meeting with the child themselves at some point. Usually this will be during the first contact (Cox, 1983).

For non-attenders at first family and individual assessment, the findings are very comparable with those o f Shapiro and Budman (Shapiro & Budman, 1973), who randomly assigned a third o f referrals to family assessments: the remainder to individual. They argued that the similarity in failure rates between those requested to attend individually and those requested to attend as a family points to such families being resistant to any therapeutic intervention. In the same study, families were not only assigned to different initial assessments but also different treatment styles, since treatment was expected to continue in the same mode as the assessment. This was not so in the present study. The therapists were at liberty to change style after the initial contact. This freedom for therapists to act as they saw fit may account for lack o f difference in early dropout according to style o f first assessment. Shapiro and Budman reported 29% early termination with family therapy compared with 18% early termination for individual therapy. In the present study, eight (14%) seen initially as a family and seven (16.3%) seen individually did not enter long term therapy. However, the second contact was different from the first in 31 (44.3%) instances and the long term mode of therapy was quite often different from the initial assessment. This could mean that the therapists were sensitive to what would sustain collaboration as well as what would assist further assessment or treatment, and so obviated the higher fall out that may occur if family therapy is pursued in a doctrinaire fashion. Low social class was common amongst referrals, and this has been found to be associated with difficulty in engagement in family therapy (Slipp et al., 1974).

Although the results could suggest advantages arising from flexibility of approach, non-attendance at second appointment was twice as common if the intention was to change from the mode used at first contact. This appeared to be o f more concern if the move was from individual to family than vice versa. These results are non-significant but percentage differences are quite substantial.

This clearly merits further investigation. If substan- tiated, it would have implications for clinical prac- rice. It suggests that if family assessment is likely to be useful, initial assessments should start with the whole family.

Psychometric assessment was more commonly requested after family assessment. The resources for psychometry were limited and had to be used in a discriminating fashion. It may be that clinicians felt less confident o f their evaluation o f children's cognitive level during family assessment. The vast majority o f children attending the clinic were within the normal range o f intelligence. However, educational problems were very c o m m o n and these were often usefully clarified by psychometry. Initial individual assessment interviews were not used for this purpose, so that the results are surpris- ing but make it clear that at least as employed in this clinic, family assessment did not preclude use o f other assessment methods.

Many staff in the clinic were at the time of the study less familiar with family treatment methods. Therapists tended to stay solely in the individual mode of treatment if they originally assessed in that mode and include at least some family work ifini- rial assessment was with the family. However the needs o f the case also appear to have influenced long term treatment approaches. Style ofinirial assessment did not seem to affect the mothers' perception of their ability to communicate about difficulties nor o f the helpfulness o f the occasion, but children felt less able to communicate effectively when assessment was in the family mode. Later attendance was better when the mothers' said they felt less worried after the first interview.

The study does not address the effectiveness of treatment but it demonstrates the way in which clinics can use research to disentangle factors which may influence co-operation in therapy.

Acknowledgements

This research would not have been possible without the contribution o f all staffat the Camberwell Child Guidance Unit in South London and the families who attended during the period of the research.

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A comparison of Individual and Family Approaches to Initial Assessment

R~sum~

L'&ude avait pour but d'examiner l'influence du mode initial d'~valuation sur l'assistance, l'6valu- ation ult6rieure et le traitement. 100 enfants nou- vellement r6f~r6s / t u n service de sant6 mentale pour enfants furent d6sign& par randomisation en fonction de (1) l'~valuation familiale initiale, Pen- rant et la famille vus ensemble ou (2) l'6valuation individueUe, l'enfant et les parents vus en parall61e. Ceux qui reCoivent une lettre individuelle de rendez-vous y viennent plus r6guli6rement parce que les parents n 'emm~nent par toujours les enfants avec eux en r6ponse ~ une lettre familiale de rendez-vous. L'absence au 2~me rendez-vous survient deux lois plus souvent s'il y a eu changement de la personne ~ qui il 6tait demand~ de venir. L'6va- luation psychom6trique &ait plus souvent deman- d~e ~ la suite d 'un entretien familial intitial. Le mode de traitement ~ long terme est partiellement, mais pas totalement influenc~ par la m6thode ini- dale d'~valuation. Les r6sultats sugg~rent qu'une coop6ration soutenue avec un tmitement ~ long terme survient plus habituellement, quand les cliniciens changent les membres de la famille avec lesquels ils travaillent selon les besoins du cas.

Zusammenfassung

Die Studie hatte zum Ziel, den EinfluB der initialen Vorgehensweise (Einzel- bzw. Familien- Erstgespr~ich) im Hinblick auf die Mitarbeit und zu einem sp~iteren Zeitpunkt die Beurteilung des Behandlungserfolgs zu untersuchen. 100 Kinder, die neu an eine kinderpsychiatrische Einrichtung tiberwiesen worden waren, wurden randomisiert (1) nach einem Familien-Erstgespr~ch (i), in dem Kind und Familie gemeinsam vorgestellt wurden, und (2) nach einem Einzel-Erstgespr~tch (ii), indem Kind und Familie parallel vorgestellt wurden, zugeteilt. Diejenigen, die mit individuellen Briefen einbestellt worden waren, nahmen zu einem grOBerem Prozentsatz teil, well die Eltern nicht immer alle ihre Kinder mitbrachten nach Er- halt eines an die ganze Familie gerichteten Einbes- tellungsschreibens. Der zweite Terrain wurde doppelt so h~iufig nicht wahrgenommen, wenn ein Wechsel der eingeladenen Person vorgenommen wurde. Psychometrische Erhebungen wurden h~iufiger erbeten nach einem initialen Familienin- terview. Langfristig schien der Therapieverlauf

teilweise, aber nicht g~inzlich durch die Art der initialen Erhebung beeinfluBt. Die Ergebnisse deu- ten darauf hin, dab best~ndige Mitarbeit im Rah- men einer Langzeittherapie eher erreichbar ist, wenn Kliniker gem~ifl den Anforderungen des Fal- les mit unterschiedlichen Familienmitgliedern ar- beiten.

References

Cox, A. (1983). Clinical assessment of the emotionally disturbed child and his family. In G.F.M. Russell & L.A. Hersov (Eds.) Handbook of Psychiatry: 4: The Neuroses and Personality Disorders (pp 68-71). Cam- bridge: Cambridge University Press.

Cox, A. (1994). Diagnostic appraisal. In M. gutter, E. Taylor & L. Hersov (Ecls.) Child and Adolescent Psy- chiatry. Modern Approaches (3rd. ed., pp. 22-33). Ox- ford: Blackwell Scientific Publications.

Churven, P.G. (1978). Parental attitudes to family assessment in a child psychiatry setting. Journal of Child Psychology and Psychiatry, 19, 33--41.

Cottrell, D., Hill, P., Walk, D., Dearnaly, J. & Lero- theou, A. (1988). Factors influencing non-attendance at child psychiatry outpatient appointments. British

Journal of Psychiatry, 152, 201-204.

Eminson, M. (1986) Clinic refusers - a brief study of non-attendance at an out-patient clinic for adoles~ cents. Newsletter of the Association of Child Psychology and Psychiatry, 8, 23-26.

Eminson, M. (1988). A comparison of data obtained from initial individual and family interviews with adolescents and their parents. Paper presented to An- nual Residential Conference of the Child & Adoles- cent Psychiatry Section of the Royal College of Psychiatrists, Sheffield, September 1988.

Heubeck, B., Watson, J. & Russell, G. (1986). Father involvement and family therapyl In M. E. Lamb (Ed.) The Father's Role: Applied Perspectives. New York: Wiley.

Kourany, R.F.C., Garber, J. & Tornusciolo, G. (1990). Improving first appointment attendance rates in child psychiatry outpatient clinics. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 657- 660.

Shapiro, R.J. & Budman, S.H. (1973). Defection, termination and continuation in family and individual therapy. Family Process 12, 55-67.

Slipp, S., Ellis, S. & Kressel, K. (1974). Factors associated with engagement in family therapy. Family Process 13, 413--428.

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