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Psychoeducational treatment for school-aged children with bipolar disorder

  • MARY A. FRISTAD (a1)
Abstract

Bipolar disorder (BPD) has received increasing attention from public and professional sources. Although pharmacologic treatments are considered the sine qua non in the treatment of youth with BPD, psychosocial interventions are critical to assist the child and family cope with symptoms that carry with them significant morbidity and mortality. Treatments developed to date are few in number; all are psychoeducationally based, using cognitive–behavioral and family systems interventions within a biopsychosocial framework. This paper reviews possible mediators of outcome, including caregiver concordance, children's social skills, hopelessness, and family stress. The author has developed two family-based psychoeducational interventions for the treatment of youth with BPD: multifamily psychoeducation groups (MFPG) and individual family psychoeducation (IFP). These treatments are both described and the results from a previously published randomized clinical trial (RCT) of MFPG are summarized. Then, new findings from an RCT of IFP are presented, along with preliminary pilot data from an expanded version of IFP. The paper concludes with recommendations for future research.This paper was supported by grants to the author from the National Institute of Mental Health (R01-MH61512) and the Ohio Department of Mental Health (ODMH-743074 and 734030).

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Corresponding author
Address correspondence and reprint requests to: Mary A. Fristad, Division of Child & Adolescent Psychiatry, Ohio State University, 1670 Upham Drive Suite 460G, Columbus, OH 432101-1250; E-mail: Fristad.1@osu.edu
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REFERENCES

Alloy, L. B., Reilly-Harrington, N., Fresco, D. M., Whitehouse, W. G., & Zechmeister, J. S. (1999). Cognitive styles and life events in subsyndromal unipolar and bipolar disorders: Stability and prospective prediction of depressive and hypomanic mood swings. Journal of Cognitive Psychotherapy, 13, 2140.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Anderson, C. M., Reiss, D. J., & Hogarty, G. E. (1986). Schizophrenia and the family: A practitioner's guide to psychoeducation and management. New York: Guilford Press.
Asarnow, R. F. (1987). The interaction between family transactions and individual differences in the attentional processes of schizophrenic patients. In M. J. G. Kurt Hahlweg (Ed.), Understanding major mental disorder: The contribution of family interaction research (pp. 91102). New York: Family Process Press.
Asarnow, J. R., Goldstein, M. J., Tompson, M., & Guthrie, D. (1993). One-year outcomes of depressive disorders in child psychiatric in-patients: Evaluation of the prognostic power of a brief measure of expressed emotion. Journal of Child Psychology and Psychiatry and Allied Disciplines, 34, 129137.
Asarnow, J. R., Tompson, M., Hamilton, E. B., Goldstein, M. J., Guthrie, D. (1994). Family expressed emotion, childhood-onset depression, and childhood-onset schizophrenia spectrum disorders: Is expressed emotion a nonspecific correlate of child psychopathology or a specific risk factor for depression? Journal of Abnormal Child Psychology, 22, 129146.
Asarnow, J. R., Tompson, M. C., Woo, S. M., & Cantwell, D. (2000). Is family expressed emotion a specific risk factor for depression in youth or a nonspecific correlate of youth psychopathology? Journal of Abnormal Child Psychology, 29, 573583.
Brent, D. A., Poling, K., McKain, B., & Baugher, M. (1993). A psychoeducational program for families of affectively ill children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 770774.
Brown, G. W., Birley, J. L., & Wing, J. K. (1972). Influence of family life on the course of schizophrenic disorders: A replication. British Journal of Psychiatry, 121, 241258.
Brown, G. W., Carstairs, G. M., & Topping, G. (1958). Post hospital adjustment of chronic mental patients. Lancet, ii, 685689.
Brown, G. W., Monck, E. M., Carstairs, G. M., & Wing, J. K. (1962). Influence of family life on the course of schizophrenic illness. British Journal of Preventive and Social Medicine, 16, 5568.
Burns, B. J., Hoagwood, K., & Mrazek, P. J. (1999). Effective treatment for the mental disorders in children and adolescents. Clinical and Family Psychology Review, 2, 199254.
Butzlaff, R. L., & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry, 55, 547552.
Carlson, G. A. (2005). Diagnosing bipolar disorder in children and adolescents. Child and Adolescent Psychopharmacology News, 10, 16.
Christie-Mizell, C. (2003). Bullying: The consequences of interparental discord and child's self-concept. Family Process, 42, 237251.
Clarkin, J. F., Carpenter, D., Hull, J., Wilner, P., & Glick, I. (1998). Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses. Psychiatric Services, 49, 531533.
Clarkin, J. F., Glick, I. D., Haas, G. L., Spencer, J. H., Lewis, A. B., Peyser, J., et al. (1990). A randomized clinical trial of inpatient family intervention. V: Results for affective disorders. Journal of Affective Disorders, 18, 1728.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum.
Cole, D. A., & Rehm, L. P. (1986). Family interaction patterns and childhood depression. Journal of Abnormal Child Psychology, 14, 297314.
Colom, F., Vieta, E., Martínez-Arán, A., Reinares, M., Goikolea, J. M., Benabarre, A., et al. (2003). A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Archives of General Psychiatry, 60, 402407.
Craddock, N., & Jones, I. (1999). Genetics of bipolar disorder. Journal of Medical Genetics, 36, 585594.
Crick, N. R., & Dodge, K. A. (1995). A review and reformulation of social information-processing mechanisms in children's social adjustment. Psychological Bulletin, 115, 74101.
Davidson, K. H., & Fristad, M. A. (in press). Family psychoeducation for children with bipolar disorder. In B. Geller & M. DelBello (Eds.), Treating child & adolescent bipolar disorder. New York: Guilford Press.
Davidson, K. H., & Fristad, M. A. (2006). The Treatment Beliefs Questionnaire (TBQ): An instrument to assess parent and child beliefs about the severity of the child's illness and treatment needs. Psychological Services, 3, 115.
Davidson, K. H., Fristad, M.A., & Goldberg-Arnold, J. S. (2006). The medication usage and service provider grids: A new method for measuring Treatment as Usual (TAU). Manuscript submitted for publication.
Deal, J. E., Halverson, C. F., & Wampler, K. S. (1989). Parental agreement on child-rearing orientations: Relations to parental, marital, family, and child characteristics. Child Development, 60, 10251034.
DelBello, M. P., & Kowatch, R. A. (2003). Neuroimaging in pediatric bipolar disorder. In B. Geller & M. P. DelBello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 158174). New York: Guilford Press.
Dodge, K. A., Pettit, G. S., McClaskey, C. L., & Brown, M. (1986). Social competence in children. Monographs of the Society for Research in Child Development, 51(2, Serial No. 213).
Dreier, M. P., & Lewis, M. G. (1991). Support and psychoeducation for parents of hospitalized and mentally ill children. Health and Social Work, 16, 1118.
Ellicott, A., Hammen, C., Gitlin, M., Brown, G., & Jamison, K. (1990). Life events and the course of bipolar disorder. American Journal of Psychiatry, 147, 11941198.
Falloon, I. R., & Pederson, J. (1985). Family management in the prevention of morbidity of schizophrenia: Clinical outcome of a two-year longitudinal study. Archives of General Psychiatry, 42, 887896.
Findling, R. L., Kowatch, R. A., & Post, R. M. (2003). Pediatric bipolar disorder. London: Dunitz.
Frank, E., Hlastala, S., Ritenour, A., Houck, P., Tu, X. M., Monk, T. H., et al. (1997). Inducing lifestyle regularity in recovering bipolar disorder patients: Results from the Maintenance Therapies in Bipolar Disorder Protocol. Society of Biological Psychiatry, 41, 11651173.
Friedmann, M. S., & Goldstein, M. J. (1993). Relatives' awareness of their own expressed emotion as measured by a self-report adjective checklist. Family Process, 32(4), 459471.
Fristad, M. A., Arnett, M. M., & Gavazzi, S. M. (1998). The impact of psychoeducational workshops on families of mood-disordered children. Family Therapy, 25, 151159.
Fristad, M. A., Davidson, K. E., & Leffler, J. (2006). Thinking–feeling–doing: A cognitive-behavioral therapeutic technique for mood disordered children. Manuscript submitted for publication.
Fristad, M. A., & Gavazzi, S. M. (1994). Psychoeducation evaluation forms. Unpublished manuscript, Ohio State University, Columbus.
Fristad, M. A., Gavazzi, S. M., Centolella, D. M., & Soldano, K. W. (1996). Psychoeducation: A promising intervention strategy for families of children and adolescents with mood disorders. Contemporary Family Therapy: An International Journal, 18, 371384.
Fristad, M. A., Gavazzi, S. M., & Mackinaw-Koons, B. (2003). Family psychoeducation: An adjunctive intervention for children with bipolar disorder. Biological Psychiatry, 53, 10001008.
Fristad, M. A., Gavazzi, S. M., & Soldano, K. W. (1999). Naming the enemy: Learning to differentiate mood disorder “symptoms” from the “self”that experiences them. Journal of Family Psychotherapy, 10, 8188.
Fristad, M. A., Gavazzi, S. M., Soldano, K. W. (1998). Multi-family psychoeducation groups for childhood mood disorders: Program description & preliminary efficacy data. Contemporary Family Therapy, 20, 385402.
Fristad, M. A., & Goldberg-Arnold, J. S. (2003). Family interventions for early-onset bipolar disorder. In B. Geller & M. P. Delbello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 295313). New York: Guilford Press.
Fristad, M. A., Goldberg-Arnold, J. S., & Gavazzi, S. M. (2002). Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Bipolar Disorder, 4, 254262.
Fristad, M. A., Goldberg-Arnold, J. S., & Gavazzi, S. M. (2003). Multifamily psychoeducation groups (MFPG) in the treatment of children with mood disorders. Journal of Marital and Family Therapy, 29, 491504.
Gavazzi, S. M., Fristad, M. A., & Law, J. C. (1997). The Understanding Mood Disorders Questionnaire. Psychological Reports, 81, 172174.
Geller, B., Craney, J. L., Bolhofner, K., DelBello, M. P., Axelson, D., & Luby, J. (2003). Phenomenology and longitudinal course of children with a prepubertal and early adolescent bipolar disorder phenotype. In B. Geller & M. P. DelBello, (Eds.), Bipolar disorder in childhood and early adolescence (pp. 2550). New York: Guilford Press.
Geller, B., Craney, J. L., Bolhofner, K., DelBello, M. P., Williams, M., & Zimerman, B. (2001). One-year recovery and relapse rates of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry, 158, 303305.
Geller, B., Craney, J. L., Bolhofner, K., Nickelsburg, M. J., Williams, M., & Zimerman, B. (2002). Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry, 159, 927933.
Geller, B., & DelBello, M. P. (Eds.). (2003). Bipolar disorder in childhood and early adolescence. New York: Guilford Press.
Geller, B., Tillman, R., Craney, J. L., & Bolhofner, K. (2004). Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Archives of General Psychiatry, 61, 459467.
Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., & Delbello, M. P. (2000). Diagnostic characteristics of 93 cases of prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 10, 157164.
Goldberg-Arnold, J. S., & Fristad, M.A. (1999). Medication usage and service provider grids. Unpublished manuscript, Ohio State University, Columbus.
Goldberg-Arnold, J. S., & Fristad, M A. (2003). Psychotherapy with children diagnosed with early-onset bipolar disorder. In B. Geller & M. DelBello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 272294). New York: Guilford Press.
Goldberg-Arnold, J. S., Fristad, M. A., & Gavazzi, S. M. (1999). Family psychoeducation: Giving caregivers what they want and need. Family Relations, 48, 411417.
Goldstein, M. J., Rodnick, E. H., Evans, J. R., May, P. R., & Steinberg, M. (1978). Drug and family therapy in the aftercare of acute schizophrenics. Archives of General Psychiatry, 35, 11691177.
Goodman, S. H., Adamson, L. B., Riniti, J., & Cole, S. (1994). Mothers' expressed attitudes: Associations with maternal depression and children's self-esteem and psychopathology. Journal of the American Academy of Child & Adolescent Psychiatry, 33, 12651274.
Hawley, K. M., & Weisz, J. R. (2003). Child, parent, and therapist (dis)agreement of target problems in outpatient therapy: The therapist's dilemma and its implications. Journal of Consulting and Clinical Psychology, 71, 6270.
Henry, B., Moffitt, T. E., Robins, L., & Earls, F. (1993). Early family predictors of child and adolescents antisocial behaviour: Who are the mothers of delinquents? Criminal Behaviour and Mental Health, 3, 97118.
Hogarty, G. E., Anderson, C. M., Reiss, D. J., & Kornblith, S. J. (1991). Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia: II. Two-year effects of a controlled study on relapse and adjustment. Archives of General Psychiatry, 48, 340347.
Holder, D., & Anderson, C. (1990). Psychoeducational family intervention for depressed patients and their families. In G. I. Keitner (Ed.), Depression and families: Impact and treatment. Washington, DC: American Psychiatric Press.
Honig, A., Hofman, A., Rozendaal, N., & Deingemans, P. (1997). Psychoeducation in bipolar disorder: Effect on expressed emotion. Psychiatry Research, 72, 1722.
Hooley, J. M. (1998). Expressed emotion and psychiatric illness: From empirical data to clinical practice. Behavior Therapy, 29, 631646.
Hooley, J. M., Orley, J., & Teasdale, J. D. (1986). Levels of expressed emotion and relapse in depressed patients. British Journal of Psychiatry, 148, 642647.
Jacob, T., Grounds, L., & Haley, R. (1982). Correspondence between parents' reports on the Behavior Problem Checklist. Journal of Abnormal Psychology, 10, 593608.
Johnson, S. L., & Miller, I. (1997). Negative life events and time to recovery from episodes of bipolar disorder. Journal of Abnormal Psychology, 106, 449457.
Joiner, T. E., Vohs, K. D., Rudd, M. D., Schmidt, N. B., & Pettit, J. W., (2003). Problem-solving and cognitive scars in mood and anxiety disorders: The sting of mania. Journal of Social and Clinical Psychology, 22, 192212.
Jordan, K., Excell, L., & Waggoner, D. (1999). The child, adolescent, and their families, and training for student therapists. Family Therapy, 26, 5155.
Jouriles, E. N., Murphy, C. M., Farris, A. M., Smith, D. A., Richters, J. E., & Waters, E. (1991). Marital adjustment, parental disagreements about child rearing, and behavior problems in boys: Increasing the specificity of the marital assessment. Child Development, 62, 14241433.
Kaufman, A. S., & Kaufman, N. L. (1990). Kaufman Brief Intelligence Test manual. Circle Pines, MN: American Guidance Service.
Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65, 366380.
Koenig, J. E., Sachs-Ericsson, N., & Miklowitz, D. J. (1997). How do psychiatric patients experience interactions with their relatives. Journal of Family Psychology, 11, 251256.
Kowatch, R. A., Fristad, M. A., Birmaher, B., Wagner, K. D., Findling, R., Hellander, M., et al. (2005). Treatment guidelines for children and adolescents with bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 213235
Lamb, M. E., Hwang, C. P., & Broberg, A. (1989). Associations between parental agreement regarding child-rearing and the characteristics of families and children in Sweden. International Journal of Behavioral Development, 12, 115129.
Lau, S., & Pun, K. L. (1999). Parental evaluations and their agreement: Relationship with children's self-concepts. Social Behavior and Personality, 27, 639650.
Lewinsohn, P. M., Klein, J. R., & Klein, D. N. (1995). Bipolar disorder in a community sample of older adolescents: Prevalence, phenomenology, comorbidity and course. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 454463.
Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003). Epidemiology and suicidal behavior. In B. Geller & M. P. DelBello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 724). New York: Guilford Press.
Lindsey, E. W., & Mize, J. (2001). Interparental agreement, parent–child responsiveness, and children's peer competence. Family Relations: Interdisciplinary Journal of Applied Family Science, 50, 348354.
Lish, J. D., Dime-Meenan, S., Whybrow, P. C., Price, R. A., & Hirschfeld, R. M. (1994). The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. Journal of Affective Disorders, 31, 281294.
Lofthouse, N., & Fristad, M. A. (2004). Psychosocial interventions for children with bipolar disorder. Clinical Child and Family Psychology Review, 7, 7188.
Malkoff-Schwartz, S., Frank, E., Anderson, B., Sherrill, J. T., Siegel, L., Patterson, D., et al. (1998). Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes. Archives of General Psychiatry, 55, 702707.
McFarlane, W. R. (1991). Family psychoeducational treatment. Handbook of family therapy (Vol. 2, pp. 363395): New York: Brunner/Mazel, Inc.
McFarlane, W. R. (1997). FACT: Integrating family psychoeducation and assertive community treatment. Administration and Public Policy, 25, 191198.
Miklowitz, D. J. (2005, April). New psychosocial interventions for juvenile-onset bipolar disorder. Presented at the Third Annual NIMH Pediatric Bipolar Disorder Conference, Coral Gables, Miami.
Miklowitz, D. J., George, E. L., Axelson, D. A., Kim, E. Y., Birmaher, B., Schneck, C., et al. (2004). Family-focused treatment for adolescents with bipolar disorder. Journal of Affective Disorders, 82S, S113S128.
Miklowitz, D. J., & Goldstein, M. J. (1990). Behavioral family treatment for patients with bipolar affective disorder. Behavior Modification, 14, 457489.
Miklowitz, D. J., Goldstein, M. J., & Nuechterlein, K. H. (1995). Verbal interactions in the families of schizophrenic and bipolar affective patients. Journal of Abnormal Psychology, 104, 268276.
Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1988). Family factors and the course of bipolar affective disorder. Archives of General Psychiatry, 45, 225231.
Miklowitz, D. J., & Hooley, J. M. (1998). Developing family psychoeducational treatment for patients with bipolar and other severe psychiatric disorders: A pathway from basic research to clinical trials. Journal of Marital and Family Therapy, 24, 419435.
Miklowitz, D. J., Richards, J. A., George, E. L., Frank, E., Suddath, R. L., Powell, K. B., et al. (2003). Integrated family and individual therapy for bipolar disorder: Results of a treatment development study. Journal of Clinical Psychiatry, 64, 182191.
Otto, M. W., Reilly-Harrington, N., & Sachs, G. S. (2003). Psychoeducational and cognitive–behavioral strategies in the management of bipolar disorder. Journal of Affective Disorders, 73, 171181.
Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J. (2004). Child- and family-focused cognitive behavioral therapy for pediatric bipolar disorder: Development and preliminary results. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 528537
Pollock, K. M. (2001). Exercise in treating depression: Broadening the psychotherapist's role. Journal of Clinical Psychology, 57, 12891300.
Poznanski, E. O., Grossman, J. A., Buchsbaum, Y., Banegas, M., Freeman, L., & Gibbons, R. (1984). Preliminary studies of the reliability and validity of the Children's Depression Rating Scale. Journal of the American Academy of Child Psychiatry, 23, 191197.
Quinn, C., & Fristad, M. A. (2004). Defining and identifying early-onset childhood bipolar disorder (EOPBSD). Current Psychiatry Reports, 6, 101107.
Rea, M. M., Tompson, M., Miklowitz, D. H., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family focused treatment vs. individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 71, 482492.
Schock, A. M., Gavazzi, S. M., Fristad, M. A., & Goldberg-Arnold, J. S. (2002). The role of father participation in the treatment of childhood mood disorders. Family Relations: Interdisciplinary Journal of Applied Family Studies, 51, 230237.
Schoppe, S. J., Mangelsdorf, S. C., & Frosch, C. A. (2001). Coparenting, family process, and family structure: Implications for preschoolers' externalizing behavior problems. Journal of Family Psychology, 15, 526545.
Schwartz, C. E., Dorer, D. J., Beardslee, W. R., Lavori, P. W., & Keller, M. B. (1990). Maternal expressed emotion and parental affective disorder: Risk for childhood depressive disorder, substance abuse, or conduct disorder. Journal of Psychiatric Research, 24, 231250.
Sheridan, A., & Moore, L. M. (1991). Running groups for parents with schizophrenic adolescents: Initial experiences and plans for the future. Journal of Adolescence, 14, 116.
Simoneau, T. L., Miklowitz, D. J., & Saleem, R. (1998). Expressed emotion and interactional patterns in the families of bipolar patients. Journal of Abnormal Psychology, 107, 497507.
Sisson, D. P., & Fristad, M. A. (2001). A survey of stress and support for parents of children with early-onset bipolar disorder. Bipolar Disorder, 3, 58.
Sloper, P. (1999). Models of service support for parents of disabled children. What do we know? What do we need to know? Child: Care, Health, and Development, 25, 8599.
TADS Team. (2004). Fluxetine, cognitive–behavioral therapy, and their combination for adolescents with depression. Journal of the American Medical Association, 292, 807863.
Vaughn, B. E., Block, J. H., & Block, J. (1988). Parental agreement on child rearing during early childhood and the psychological characteristics of adolescents. Child Development, 59, 10201033.
Vuchinich, S., Vuchinich, R., & Wood, B. (1993). The interparental relationship and family problem solving with preadolescent males. Child Development, 64, 13891400.
Weller, E. B., Weller, R. A., Rooney, M. T., & Fristad, M. A. (1999a). Children's interview for psychiatric syndromes (ChIPS). Washington, DC: American Psychiatric Association.
Weller, E. B., Weller, R. A., Rooney, M. T., & Fristad, M. A. (1999b). Children's interview for psychiatric syndromes—Parent version (P-ChIPS). Washington DC: American Psychiatric Association.
Yeh, M., & Weisz, J. R. (2001). Why are we here at the clinic? Parent–child (dis)agreement on referral problems at outpatient treatment entry. Journal of Consulting and Clinical Psychology, 69, 10181025.
Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability, validity and sensitivity. British Journal of Psychiatry, 133, 429435.
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