Maintenance Model of Integrated Psychosocial Treatment in Pediatric Bipolar Disorder: A Pilot Feasibility Study

doi:10.1097/01.chi.0000246068.85577.d7

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 46, Issue 2, February 2007, Pages 205-212

https://doi.org/10.1097/01.chi.0000246068.85577.d7 Get rights and content

ABSTRACT

Objective

The chronic and refractory course of pediatric bipolar disorder merits the study of adjunctive psychosocial interventions designed to facilitate long-term improvements. The objective of this study is to conduct a pilot study of a maintenance model of the child- and family-focused cognitive-behavioral therapy program (CFF-CBT), which comprises psychosocial booster sessions and optimized pharmacotherapy, and to assess whether positive effects seen after the acute phase of treatment could be sustained over time with the use of this model.

Method

The study design was an open trial with the goal of assessing feasibility of such a maintenance model over time. Thirty-four patients 5 to 17 years of age who underwent CFF-CBT were delivered the maintenance model of treatment over a 3-year period and assessed for symptom changes (Children's Global Impressions Scale-Bipolar) and global functioning (Children's Global Assessment Scale).

Results

Results indicated that participation in the maintenance model of CFF-CBT treatment was associated with positive effects in symptoms and functioning over the 3-year follow-up period. There were no statistically significant differences in postacute-phase treatment scores and scores at years 1, 2, or 3 on any study measures, indicating the maintenance of clinically significant improvements.

Conclusions

These findings suggest that maintenance treatment models are feasible and may help facilitate the long-term management of symptoms. Controlled clinical trials that build on this model will help advance treatments for pediatric bipolar disorder toward addressing the low recovery and high relapse rates associated with the disorder.

Section snippets

Entry Criteria

Entry criteria for this study included patients with PBD who completed the initial CFF-CBT treatment in the Pediatric Mood Disorders Program at the University of Illinois at Chicago (Pavuluri et al., 2004b). Patients were eligible to participate if they received adequate initial treatment (defined as participation in at least 8 of 12 sessions) and were receiving medication management in our clinic.

Participants

Patients were recruited through the Pediatric Mood Disorders Program using an institutional review

RESULTS

Three years after the initial acute phase of treatment, those patients who received CFF-CBT maintenance therapy had sustained the positive effects of the initial intervention. Single-sample t tests (two-tailed) indicated that those who received the maintenance therapy model were functioning significantly better than they were before their participation in the initial intervention and maintenance phase. Single-sample t tests were used because, according to institutional review board protocol,

DISCUSSION

The present study explored the feasibility of a maintenance model of CFF-CBT for PBD that comprised a psychotherapy adjunct to optimal pharmacotherapy to address the ongoing psychosocial struggles in PBD. Challenges that arose during the initial 6 months of the follow-up period were consolidated into a structured, yet flexible, model that incorporated themes from the seven main ingredients of the initial acute-phase program of treatment to address emerging and recurring barriers to the

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Cited by (63)

Irritability, Anger, and Aggression in the Context of Pediatric Bipolar Disorder
2021, Child and Adolescent Psychiatric Clinics of North America
Citation Excerpt :
However, some psychosocial interventions tailored to youth with BD have reported improvement in these psychopathological domains. Specifically, A Child and Family Focused Cognitive Behavioral Therapy designed for patients and families with BD that integrated psychoeducation, cognitive behavioral, and interpersonal techniques found that when this intervention is added to pharmacotherapy, youth experienced improvements in measured irritability and aggressive behaviors.78–80 An adaptation for adolescents of the Family Focused Therapy81 found that among youth with BD ratings of anger and hostility in families with high levels of expressed emotion can be significantly reduced with this intervention.82
Psychotherapic interventions for bipolar disorder in children and adolescents
2017, Encephale
Depuis une quinzaine d’années, plusieurs types d’interventions psychothérapiques à destination des enfants et des adolescents présentant un trouble bipolaire ont été développés. Parmi celles-ci, celles centrées sur la famille (comme le programme family-focused treatment for adolescents with bipolar spectrum disorders) ou incluant enfants et parents (comme les programmes multi- or individual-family psychoeducational psychotherapy et child- and family-focused cognitive-behavioral therapy ou encore la thérapie comportementale dialectique) s’avèrent prometteuses. Les interventions individuelles (comme la thérapie interpersonnelle avec aménagement des rythmes sociaux et la thérapie cognitivo-comportementale) apparaissent à ce jour moins bien documentées. Quoi qu’il en soit, les études réalisées comportent toutes de nombreuses limites sur le plan méthodologique rendant difficiles l’interprétation et la généralisation de leurs résultats. C’est dire que des études complémentaires s’avèrent nécessaires pour juger de l’impact de ces interventions, notamment à long terme, sur le devenir des enfants et des adolescents bipolaires.
To review the options for psychosocial interventions in pediatric bipolar disorders.
A comprehensive literature review of randomized clinical trials and open-label studies was conducted.
Randomized controlled trials show that psychosocial interventions involving families (i.e. family-focused treatment) or individual and family therapy (i.e. multi- or individual-family psychoeducational psychotherapy, child- and family-focused cognitive-behavioral therapy, dialectical behavior therapy) may be effective through added benefit to pharmacotherapy. All these interventions share numerous common therapeutic elements such as psychoeducation and skills training. Individual interventions (i.e. interpersonal and social rhythm therapy and cognitive-behavioral therapy) are to date less well documented. However that may be, outcome studies remain few, and numerous methodological limitations (small sample sizes, designs not very rigorous) restrict the interpretability and generalisability of their results. In addition, most studies were conducted in specialty centers with highly trained therapists, and the feasibility and acceptability of these interventions in practice settings remain to be shown.
Despite recent developments in identifying effective psychosocial interventions, numerous critical gaps remain, and more longitudinal studies are needed to clarify how these interventions work.
Psychosocial interventions in the treatment of youth diagnosed or at high-risk for pediatric bipolar disorder: A review of the literature
2015, Revista de Psiquiatria y Salud Mental
El trastorno bipolar pediátrico (TBP) se ha convertido en un campo de investigación en el que los tratamientos psicosociales han proporcionado una gran cantidad de hallazgos empíricos en la última década. Abordamos esta cuestión a través de una revisión sistemática destinada a establecer su eficacia y viabilidad como terapias adyuvantes para los jóvenes con TBP o en alto riesgo de TBP. Se realizó una búsqueda exhaustiva en bases de datos entre 1990 y septiembre del 2014. En total, 33 estudios se relacionaron específicamente con el tema y 20 de ellos eran artículos originales. La evidencia muestra que tanto la «psicoeducación familiar» como la «terapia familiar para adolescentes» son tratamientos probablemente eficaces en el TBP. Del mismo modo, la «terapia cognitivo-conductual centrada en el niño y la familia» se puede caracterizar como un tratamiento en fase experimental. Las terapias restantes no obtienen suficiente apoyo empírico, ya sea por la presencia de hallazgos inconsistentes entre los distintos ensayos clínicos, ya por contar con datos únicamente provenientes de estudios de casos. Además, los resultados de los estudios sobre tratamientos psicosociales proporcionan resultados concluyentes en cuanto a la viabilidad y aceptabilidad de dichas terapias. Son necesarios ensayos clínicos controlados con muestras de mayor tamaño con el fin de disminuir las deficiencias metodológicas encontradas en una gran parte de los tratamientos descritos.
Pediatric bipolar disorder (PBD) has emerged as a research field in which psychosocial treatments have provided a plethora of empirical findings over the last decade. We addressed this issue through a systematic review aimed of establishing their effectiveness and feasibility as adjunctive therapies for youth with PBD or at high-risk for PBD. A comprehensive search of databases was performed between 1990 and September 2014. Overall, 33 studies were specifically related to the issue and 20 of them were original articles. Evidence suggests that both «multi-family psychoeducational psychotherapy» and «family-focused therapy» are possible effective treatments for PBD. Likewise, «child and family-focused cognitive-behavioral therapy» may be characterized as a treatment in its experimental phase. The remaining therapies fail to obtain enough empirical support due to inconsistent findings among clinical trials or data solely based on case reports. Studies of psychosocial treatments provide concluding results concerning their feasibility and acceptability. Larger sample sizes and more randomized controlled trials are mandatory for diminishing methodological shortcomings encountered in the treatments displayed.
Management of bipolar 1 disorder in children and adolescents
2014, Encephale
La prévalence du trouble bipolaire (TB) type I est estimée à 0,1 % chez l’enfant et l’adolescent. Bien qu’il soit rare, un intérêt grandissant est porté à ce trouble compte tenu du pronostic sévère de la maladie, du retentissement fonctionnel et du risque suicidaire élevé. Ce diagnostic est complexe, en partie à cause des comorbidités plus fréquentes à cet âge, des spécificités développementales de l’expression clinique et du recoupement symptomatique avec d’autres troubles (comme le trouble déficitaire attention-hyperactivité, TDAH). Alors que chez les adolescents, la présentation est proche de celle de l’adulte, chez les enfants prépubères, les symptômes sont plus souvent chroniques sans retour clair à une phase d’euthymie ; l’irritabilité et la labilité émotionnelle sont souvent au premier plan. Cette présentation ne répond que rarement aux critères de trouble bipolaire type I (TB-1) ; le diagnostic de trouble bipolaire non spécifié (TB-NOS) est alors souvent posé chez ces enfants aux États-Unis, ce qui a contribué à une inflation du diagnostic ces dernières années. Les études sur de telles dysrégulations émotionnelles de l’enfant ne retrouvent pas de continuité avec le TB à l’âge adulte, mais une évolution plus fréquente vers un trouble dépressif. Pour mieux identifier ces patients et éviter l’amalgame avec le TB, le diagnostic de Disruptive Mood Dysregulation Disorder (DMDD) a été proposé dans le DSM-5. Au plan de la prise en charge, l’objectif des traitements pharmacologique et psychosocial est de traiter l’épisode aigu, de prévenir la rechute, d’améliorer le fonctionnement global intercritique et de prévenir le risque suicidaire. Plusieurs traitements médicamenteux ont été évalués dans le TB-1 de l’adolescent dans des essais randomisés en double insu. Aux État-Unis, outre les sels de lithium, quatre antipsychotiques ont l’AMM pour l’épisode maniaque aigu de l’adolescent à partir de 10 à 13 ans (risperidone, olanzapine, aripiprazole et quétiapine). En France, les sels de lithium ont l’AMM à partir de 16 ans ; l’aripiprazole à partir de 13 ans. Les essais thérapeutiques sur les autres formes de TB sont peu concluants. Plusieurs stratégies psychothérapeutiques individuelles et familiales ont aussi été proposées.
Lifetime prevalence of child and adolescent bipolar 1 disorder (BD1) is nearly 0.1 %. Even though it is not a frequent disorder in young people, there is an increased interest for this disorder at this age, because of the poor outcome, the severe functional impairments and the major risk of suicide. Diagnosis is complex in view of the more frequent comorbidities, the variability with an age-dependant clinical presentation, and the overlap in symptom presentation with other psychiatric disorders (e.g. disruptive disorders in prepubertal the child and schizophrenia in the adolescent). The presentation in adolescents is very similar to that in adults and in prepubertal children chronic persistent irritability and rapid mood oscillation are often at the foreground. For a while, such presentations were considered as BD-not otherwise specified (BD-NOS), which can explain the outburst of the prevalence of bipolar disorder in children in the US. Longitudinal studies that look for the outcome of such emotional dysregulations have not revealed an affiliation with bipolar disorder spectrum, but with depressive disorders in adulthood. The diagnosis of Disruptive Mood Dysregulation Disorder was proposed in the DSM-5 to identify these children and to prevent confusion with bipolar disorder. The goals of the pharmacological and psychosocial treatments are to control or ameliorate the symptoms, to avoid new episodes or recurrences, to improve psychosocial functioning and well-being, and to prevent suicide. In the US, lithium and four atypical antipsychotics have been approved by the FDA for 10 to 13-year-olds (risperidone, olanzapine, aripiprazole and quetiapine). In France, only lithium salts (after the age of 16) and aripiprazole (after the age of 13) are recommended. Psychosocial treatments, such as a familial or individual approach are developing.
Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial
2014, Journal of the American Academy of Child and Adolescent Psychiatry
Citation Excerpt :
To our knowledge, CFF-CBT is the only single-family psychosocial treatment developed exclusively for children and preadolescents with BD that has been tested through an RCT. Data from this study were consistent with previous open trials,28-30 suggesting the feasibility of delivering CFF-CBT in an academic clinical setting. CFF-CBT families attended more sessions, were less likely to drop out, and reported higher levels of satisfaction with treatment content, structure, and impact.
Previous studies have found that family-based psychosocial treatments are effective adjuncts to pharmacotherapy among adults and adolescents with bipolar disorder (BD). The objective of this study was to compare the efficacy of adjunctive child- and family-focused cognitive-behavioral therapy (CFF-CBT) to psychotherapy as usual (control) for mood symptom severity and global functioning in children with BD.
Sixty-nine youth, aged 7 to 13 years (mean = 9.19, SD = 1.61) with DSM-IV-TR bipolar I, II, or not otherwise specified (NOS) disorder were randomly assigned to CFF-CBT or control groups. Both treatments consisted of 12 weekly sessions followed by 6 monthly booster sessions delivered over a total of 9 months. Independent evaluators assessed participants at baseline, week 4, week 8, week 12 (posttreatment), and week 39 (6-month follow-up).
Participants in CFF-CBT attended more sessions, were less likely to drop out, and reported greater satisfaction with treatment than controls. CFF-CBT demonstrated efficacy compared to the control treatment in reducing parent-reported mania at posttreatment and depression symptoms at posttreatment and follow-up. Global functioning did not differ at posttreatment but was higher among CFF-CBT participants at follow-up.
CFF-CBT may be efficacious in reducing acute mood symptoms and improving long-term psychosocial functioning among children with BD.
Examination of disruptive behavior outcomes and moderation in a randomized psychotherapy trial for mood disorders
2013, Journal of the American Academy of Child and Adolescent Psychiatry
Citation Excerpt :
The results are consistent with findings from RCTs of adolescents with depression, which indicated that DBDs did not affect treatment response.15-18 Although previous studies in youth have reported mixed findings for the effect of mood treatments on DBD symptoms, the present study suggests MF-PEP may offer some benefit for disruptive behaviors.19-27 Results also offer preliminary empirical support for treatment guidelines of mood disorders, which recommend mood stabilization or treatment of the most impairing disorder before addressing comorbidities.3-5
Multifamily psychoeducational psychotherapy (MF-PEP) is an efficacious treatment for children with mood disorders. Given the comorbidity between disruptive behaviors and mood disorders, this study examined associations between disruptive behaviors and impairment, impact of MF-PEP on disruptive behaviors, and whether disruptive behaviors affected treatment response of mood symptoms.
Secondary analyses examined a randomized controlled trial of MF-PEP versus waitlist control (N = 165 children 8–11 years old with mood disorders and their parents). Comorbid behavioral diagnoses occurred in 97% of children. All participants continued treatment as usual.
Greater degree of disruptive behaviors was associated with worse mood symptoms and impairment. Between-group analyses examining outcome of disruptive behaviors were nonsignificant. Within-group analyses and between-group effect sizes suggested that MF-PEP was associated with decreases in attention-deficit/hyperactivity disorder (d = 0.39), oppositional defiant disorder (d = 0.30), and overall disruptive behavior symptoms (d = 0.30), but not conduct disorder symptoms. Baseline severity of disruptive behaviors did not affect treatment response of mood symptoms to MF-PEP.
MF-PEP is an effective intervention for children with mood disorders and provides some benefit for disruptive behaviors. Given that disruptive behavior severity does not affect children’s ability to experience improved mood symptoms, MF-PEP may be an important early intervention for children with comorbid mood and disruptive behavior disorders. Subsequent intervention targeting behavioral symptoms after improvement in mood may be beneficial. Studies examining treatment sequencing for children with comorbid mood and disruptive behavior disorders are needed. Clinical trial registration information—Family psychoeducation for children with mood disorders; http://clinicaltrials.gov; NCT00050557.

View all citing articles on Scopus

Financial support for this study was provided by the Department of Psychiatry at the University of Illinois at Chicago.

The authors would like to acknowledge Julie Carbray, D.N.Sc., and Jodi Heidenreich, LCSW, for their integral role in conducting this research.

Disclosure: Dr. Henry serves as a consultant on methodology and statistics for United Biosource Corp. Dr. Pavuluri's work is supported by GlaxoSmithKline-NeuroHealth, Abbott, and Janssen Research Foundation. She is a consultant to Shire, Janssen, Abbott, and GlaxoSmithKline-NeuroHealth. She served on the speakers' bureaus of AstraZeneca, Janssen, Abbott, and GlaxoSmithKline-NeuroHealth. Dr. West has no financial relationships to disclose.

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ARTICLESMaintenance Model of Integrated Psychosocial Treatment in Pediatric Bipolar Disorder: A Pilot Feasibility Study

ABSTRACT

Objective

Method

Results

Conclusions

Section snippets

Entry Criteria

Participants

RESULTS

DISCUSSION

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Affect Disord

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

ARTICLES
Maintenance Model of Integrated Psychosocial Treatment in Pediatric Bipolar Disorder: A Pilot Feasibility Study