Psychotherapy Necessary for Bipolar Disorder and Severe Mood Dysregulation in Children

October 28, 2010 · Posted in Current Treatments 

TherapyDr. Janet Wozniak of Massachusetts General Hospital initiated a survey, both at MGH and in the field, to ascertain practitioners’ experience with individual and family psychotherapeutic and educational approaches to childhood-onset bipolar illness. These types of approaches appear fundamental to treating children or families in which there is bipolar illness.

It was the view of Wozniak, her survey, and many other investigators in attendance at the Pediatric Bipolar Conference in Cambridge, Massachusetts in March that such psychotherapeutic approaches are needed, and often recommended, but the availability of effective treatment and of therapists skilled in administering any of these psychotherapies in children is often lacking.

At the Pediatric Bipolar Conference in Cambridge, Massachusetts in March, James Waxmonsky, a researcher at the University of Buffalo, presented a pilot trial of a novel group-based therapy for school-age children with attention deficit hyperactivity disorder (ADHD) and severe mood dysregulation (SMD). These children were simultaneously being treated with stimulants, and following the group therapy, improvements were seen in affective symptoms and global functioning. Further controlled clinical trials of this type of therapy are indicated.

SMD is characterized by chronic irritability and profound temper outbursts in children who do not otherwise meet the mood criteria for bipolar I, II, or NOS (not otherwise specified). The SMD phenomenon has been carefully described by Dr. Ellen Leibenluft and colleagues at the National Institute of Mental Health, but psychotherapeutic and pharmacological approaches to it have not been well-delineated. In a small clinical trial of lithium for these children, the drug did not show superiority to placebo.

Waxmonsky’s treatment consisted of ten 90-minute therapy sessions for a group of parents, and ten sessions for a group of the children.

The sessions for parents consisted of the following: an introduction; social learning theory; listening and positive attending; emotion recognition; coping skills, house rules planning, and ignoring outbursts; commands and time out; anger triggers and negative family cycles; verbal and non-verbal communication; problem solving; depression; and applying skills in the real world.

The sessions for children included: an introduction; symptoms versus self; goals; emotion recognition promoting the positive; how anger looks and feels; identifying triggers and building a coping tool kit; how to stay in control of anger; perspectives and consequences; verbal and nonverbal communication; problem solving; depression and self esteem; and putting it all together.

EDITOR’S NOTE:  As emphasized on page 5, some form of psychotherapeutic intervention for child and adolescent-onset bipolar illness appears necessary. This may also be true for other non-bipolar externalizing disorders, such as SMD. A substantial amount of psychoeducation for patients and family members appears crucial to short- and long-term approaches to these debilitating illnesses.

The literature is now highly supportive of the efficacy of various psychotherapeutic approaches compared with treatment as usual in adults, adolescents, and children with bipolar disorder. Considerable data support the effectiveness of the cognitive behavioral techniques, and now the dialectical behavior therapy described by Tina Goldstein (p. 5) appears to be a useful alternative. Utilizing family-focused treatment appears to have some merit, and Mary Fristad of Ohio State University has also developed a multi-family psychoeducational approach.

These data in children are supported by controlled clinical trials in adults. David Miklowitz and colleagues at UCLA demonstrated that in adults, interpersonal social rhythm therapy, interpersonal therapy, and cognitive behavioral therapy were all superior to treatment as usual for bipolar depression, with greater improvement on these therapies in both measures of time to improvement and time to relapse into the next episode.

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