Psychotherapy of Childhood Bipolar Disorder
At the 2014 meeting of the American Academy of Child and Adolescent Psychiatry, there was an excellent symposium on different psychotherapeutic approaches for children and adolescents with bipolar disorder and related illnesses.
Amy West of the university of Illinois at Chicago started off this symposium by describing the effectiveness of child-and family-focused cognitive-behavior therapy or what is sometimes called RAINBOW therapy. Rainbow stands for Routine, Affect regulation, I can do it, No negative thinking, Be a good friend and balance life stressors, Oh how can we solve problems, and Ways to find support.
West emphasized the importance of routine in sleep, diet, medications, and homework, and indicated that frequent soothing is necessary. Posted reminders are also helpful.
Affect regulation can be encouraged by promoting coping skills, particularly around identifying what triggers mood swings and rage attacks and creating plans for dealing with them.
“I can do it” reminds parents and children to focus on strengths, successes, positive feedback, and the ability to call for help.
“No negative thinking” encourages positive restructuring and reframing of negative perspectives. Part of this includes mindfulness training for children and parents, who are taught to focus on breathing and accepting thoughts and emotions.
Being a good friend focuses on listening, engaging friends, and enhancing communication.
“Oh how can we solve problems” reminds families to have an attitude of problem solving.
Remembering ways to find support reminds parents to connect with relevant resources, and also coaches parents to be advocates for their children.
In a randomized study of 12 sessions of child and family focused cognitive behavior therapy, the children did much better than those receiving treatment as usual and showed greater improvement in mania and depression as well as overall functioning.
The second presentation was given by Mary Fristad of Ohio State University. She treated children with bipolar disorder not otherwise specified (BP-NOS) with psychotherapy and omega-3 fatty acids. Some research had suggested the efficacy of omega-3 fatty acids in childhood mood disorders and a much larger literature was positive in adult mood disorders. Given the safety of the manipulation, she felt it was worth trying in young children and those with BP-NOS who are rarely studied formally. She also cited a 2010 study by Amminger et al. in children who were at ultra high risk for schizophrenia. In that study, patients were randomized to 12 weeks of omega-3 fatty acids or placebo, and omega-3 fatty acids were associated with a very low conversion rate to full-blown psychosis, 4.9%, compared to 27.5% for those receiving placebo. Fristad’s psychotherapy also emphasized education, support, and skill building in order to enhance understanding of the illness and its treatment. This would help ensure better compliance and better treatment outcome. Her formal treatment manual is available at www.moodychildtherapy.com.
Fristad randomized children with bipolar not otherwise specified, average age 10.2 +/- 0.2 years to either her psychotherapy plus omega-3 fatty acids or therapy plus placebo. Therapy plus omega-3 was much more effective on most outcome measures.
Editor’s Note: Given the safety of omega-3 fatty acids, even these limited data would appear to justify their use in children with BP-NOS in the context of psychotherapy and psychoeducation.
The third presenter was David Miklowitz of UCLA who discussed family focused therapy. This approach has proven effective in studies of both adults and adolescents with bipolar disorder, and as well for those with prodromal symptoms. That is, if a parent had bipolar disorder and their offspring had depression, cyclothymia, or BP-NOS, family focused therapy was more effective in treating these symptoms than treatment as usual. Family focused therapy was particularly effective in children from families with high expressed negative emotion. Miklowitz highlighted the technical strategies useful in clinical practice in order to assist children and families to understand what precipitated the most recent symptoms or phase of illness, track moods and identify early warning signs and symptoms over time, promote consistent daily routines and sleep-wake habits, address issues relative to medication consistency including psychoeducation about the illness and the need for treatment with psychopharmacology, distinguish mood swings from developmentally-appropriate mood instability, and address difficulties in coming to accept the difficult realities of pediatric mood disorders and the functional limitations they impose.
Miklowitz also indicated that it is crucial to enhance communication within the family and to decrease levels of negative expressed emotion. Problem-solving strategies for all of these issues are a key to success.
The last talk was given by Tina Goldstein of Pittsburgh on the use of dialectical behavior therapy for adolescents with bipolar disorder. This therapy focuses on skill building, particularly mindfulness. Skills training is also offered the areas of psychoeducation, distress tolerance, emotion regulation, and taking the middle road (looking for alternative options to either extreme). Goldstein randomized adolescents on a two to one ratio to dialectical behavior therapy or standard psychotherapeutic treatment. All of the participants also received pharmacotherapy. Goldstein found a much higher rate of compliance and staying in treatment in those with dialectical behavior therapy compared to routine psychotherapy. There was also a significant decrease in depressive symptoms, a doubling of time euthymic, a threefold decrease in suicidal ideation, and an improvement in behavior regulation. She gave some examples of how one might develop stress tolerance and helping adolescents to use self-soothing techniques by associating images, sounds, and smells with positive feelings and building a toolbox for using these techniques. All of these approaches were delivered in the context of 16 weeks of multifamily group treatment.
Researcher Eric Youngstrom was the discussant of the symposium and highlighted the excellence of the talks and the effectiveness of all of the psychotherapeutic approaches presented. However, he described the need to enhance availability of these techniques to the general public, noting that in his hometown of Chapel Hill, North Carolina, there were no experts who were able to deliver these techniques. He raised the issue of how delivery of these treatments could be scaled up so that they are much more widely available to the general community.
Editor’s Note: At this point, parents should be aware that there are specialized types of highly effective psychotherapy for children and adolescents with full-blown bipolar disorder, its spectrum including bipolar not otherwise specified, and disorders that may develop into bipolar disorder, such as depression and cyclothymia. Appropriate therapies can be accessed through the research groups described in this article and their trainees at UCLA, Pittsburgh, Ohio State University, as well as the University of Illinois at Chicago and perhaps at other academic centers of excellence in other cities.
If families are unable to access these locations, they should continue to seek expert treatment that includes some of the core components of the psychotherapies described above. In particular, education about the illness and its treatments is crucial, as is recognizing early signs and symptoms and developing plans to address these before a major mood episode develops. In this regard, charting mood on a regular basis may be invaluable, not only to recognize mood, behavior, and sleep fluctuations, but also to evaluate the effectiveness of treatment approaches.
