Heading Off Early Symptoms of Bipolar Disorder in Children at High Risk
At the American Academy of Child and Adolescent Psychiatry (AACAP) annual meeting in Toronto in October 2011, there was a symposium on risk and resilience factors in the onset of bipolar disorder in children who have a parent with the disorder.
Family Focused Therapy Highly Encouraged
Amy Garrett reported that family focused therapy (FFT) in those at risk for bipolar disorder was effective in ameliorating symptomatology compared to treatment as usual. Family focused therapy, pioneered by Dave Miklowitz, PhD of UCLA involves three components. The first component is education about the illness and methods of self-management. The second is enhancement of communication in the family with practice and rehearsal of new modes of conversation. The third component is assistance with problem solving.
In Garrett’s study, 50 children aged 7 to 17 were randomized to family focused treatment or treatment as usual. These children were not only at high risk for bipolar disorder, they were already prodromal, meaning they were already diagnosable with bipolar not otherwise specified (BP-NOS), cyclothymia, or major depressive disorder, and had also shown concurrent depressive and/or manic symptoms in the two weeks prior to the study. At baseline, compared to controls, these children at high risk for full-blown bipolar disorder by virtue of a parental history of the illness showed increased activation of the amygdala and decreased activation of the prefrontal cortex. Most interestingly, after improvement with the family focused therapy (FFT), amygdala reactivity to emotional faces became less prominent and dorsolateral prefrontal cortical activity increased in proportion to the degree of the patient’s improvement.
The discussant for the symposium was Kiki Chang of Stanford University, who indicated that the results of this study of family focused therapy were already sufficient to convince him that FFT was a useful therapeutic procedure in children at high risk for bipolar disorder by virtue of having a parent with a history of bipolar illness. Chang is now employing the therapy routinely in all of his high-risk patients.
Editors Note: This is an extremely important recommendation as it gives families a specific therapeutic process in which to engage children and others in the family when affective behavior begins to become abnormal, even if it does not meet full criteria for a bipolar I or bipolar II disorder.
FFT also meets all the important criteria needed for putting it into widespread clinical practice. Family focused therapy has repeatedly been shown to be effective in adults and adolescents with bipolar illness and now also in these children who are prodromal. The psychoeducational part of FFT is common sense, and dealing with communication difficulties and assisting with problem solving also have merit in terms of stress reduction. Finally, this treatment intervention appears to be not only safe but also highly effective in a variety of different prodromal presentations of affect disorders even if children do not meet full criteria for bipolar disorder. While the few studies of early intervention with psychopharmacological agents have not yet identified efficacious medications for the prodromes of bipolar disorder and in particular medications with a high degree of safety, such family focused therapy appears to be an ideal early intervention.
I would concur with Dr. Chang’s assessment. Family focused therapy (FFT) should be offered to all children with this high-risk status who have begun to be symptomatic. Early onset of unipolar depressive disorder or of bipolar disorder carries a more adverse prognosis than the adult onset variety and thus should not be ignored. If more serious illness is headed off early, it even raises the possibility that the full-blown illness will not develop at all.
Gray Matter Volume Abnormalities
Tomas Hajek of Dalhousie University in Halifax presented data indicating that in children at high risk for bipolar disorder, gray matter volume in the right inferior frontal gyrus is increased. The left inferior frontal gyrus is related to Broca’s area and is important for language. In contrast, the right side of the inferior frontal gyrus deals with response inhibition, autobiographical memory, mirror neurons, and empathy.
Interestingly, in ill patients the gray matter volume in the right inferior frontal gyrus is decreased. Other findings in the literature indicate that a duration of illness longer than 10 years is associated with decreases in gray matter volume in this area of the brain. Hajek also found that lithium treatment could lessen the degree of prefrontal cortical volume loss over time.
Editors Note: The findings raise the interesting conundrum that in those at high risk but unaffected by bipolar disorder, this area of brain is larger than normal, but in those who become ill, the volume of this area is slightly smaller, and the volume decreases as the illness continues. The mechanism of these effects is unknown, but these findings (which were replicated in two independent samples) suggest the possibility that increased volume in the inferior frontal cortex could be a marker of vulnerability to bipolar disorder in those at high risk but not yet ill.
Poor Cognitive Control in Children at High Risk
Pilyoung Kim of the National Institute of Mental Health (NIMH) reported that young children at high risk for bipolar disorder have difficulties with cognitive control, especially with more difficult tasks. Interestingly, the ventrolateral prefrontal cortex, which is near the inferior frontal cortex, showed increased activity in association with difficulties in working memory on a two-back test (where children view a series of symbols and must remember the symbol they viewed not one symbol back, but two back.)
Decreased Neuronal Connectivity in Children at High Risk
Cecile Lana DeLuca reported that there are high levels of neuronal connectivity between the dorsolateral prefrontal cortex and the amygdala in healthy young people, but decreased connectivity of these two important regions in well children at high risk for bipolar disorder by virtue of having a parent with the illness.
