Children and adolescents with bipolar spectrum disorders experience extreme and chronic mood dysregulation, including irritability, rage episodes, excessive elation or sadness, distractibility, grandiosity, a decreased need for sleep, and poor judgment. Unlike their adult counterparts, youth with bipolar disorder tend to exhibit longer episodes with rapid cycling and mixed mood states (i.e., depression and mania/hypomania together). Not surprisingly, the chronicity and severity of pediatric bipolar disorder (PBD) symptoms results in significant psychosocial impairment. Specifically, youth with bipolar spectrum disorders demonstrate academic underperformance and disruptive school behavior; limited peer networks and poor social skills; and increased family stress. As such, cognitive behavioral therapy (CBT) methods for PBD have been developed as an adjunct to pharmacotherapy to address the complex constellation of symptoms and associated social, academic, and family difficulties.
Although existing treatment approaches differ in their emphasis and prioritization of CBT methods, various therapy components target the core areas of impairment in PBD. A primary component is psychoeducation to build the family's understanding of the symptoms, etiology, and chronicity of PBD. Treatment also focuses on the development of affect regulatory strategies, including self-monitoring of mood states, recognizing and labeling feelings, and coping skills to manage expansive, negative, and irritable moods. In addition, youth and parents may be instructed in cognitive restructuring techniques to reduce negative thought patterns (e.g., thought stopping, reframing situations positively, modifying thoughts, and use of positive self-talk/mantras during difficult situations). Further, parent training in behavioral management strategies that are specific to the rage episodes common in PBD is incorporated to help families prevent and cope with these affective "storms." Strategies include establishing simple and predictable routines, minimizing transitions, emphasizing the timing and tone of interactions during episodes (e.g., helping to soothe and contain the child during the acute episode, and enforcing consequences only once the behavior has stabilized), and using positive reinforcement. Youth and parents are also engaged in problem-solving skills training to target interpersonal and family difficulties, as well as to enhance self-efficacy related to coping with the disorder. Similarly, social skills training focuses on role-play, listening and communication skills, and empathy to improve the interpersonal difficulties associated with PBD. Finally, parents are encouraged to engage in pleasant, relaxing activities and to utilize their support networks to help cope with the demands of caring for a child with PBD.
Cognitive behavioral treatment models for PBD have shown promising results among youth when incorporated as an adjunct to pharmacotherapy. Studies indicate that individual/family- and group-based formats of child- and family-focused CBT (CFF-CBT), a manual-based model that incorporates the treatment methods described above, resulted in improved PBD symptoms and psychosocial functioning among youth. A randomized controlled trial is currently underway to further establish the efficacy of CFF-CBT. In addition, a multi-family psychoeducation group psychotherapy model (MFPG; a group treatment for parents and children that focuses on psychoeducation, problem-solving, and coping skills) is associated with improvement in mood symptom severity. Last, a family-focused treatment model for adolescents (FFT-A), which includes psychoeducation, communication training, and problem-solving training, has been shown to improve depressive symptoms, episode duration, and recovery.
References and Additional Readings
Child- and Family- Focused Psychotherapy
Pavuluri, M.N., Graczyk, P.A., Henry, D.B., Carbray, J.A., Heidenrich, 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 and Adolescent Psychiatry, 43, 528 - 537.
West, A.E., Henry, D.B., & Pavuluri, M. (2007). Maintenance model of integrated psychosocial treatment in pediatric bipolar disorder: A pilot feasibility study. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 205 - 212.
West, A.E., Jacobs, R.H., Westerholm, R., Lee, A., Carbray, J., Heidenrich, J., & Pavuluri, M.N. (2009). Child and family-focused cognitive behavioral therapy for pediatric bipolar disorder: Pilot study of group treatment format. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 18, 239 - 256.
Multifamily Psychoeducational Psychotherapy
Fristad, M.A., Goldberg-Arnold, J., & Gavazzi, S. (2002). Multi-family psychoeducation groups (MFPG) for parents of children with bipolar disorder. Bipolar Disorder, 4, 254 - 262.
Fristad, M.A., Verducci, J.S., Walters, K., & Young, M.E. (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66, 1013-1021.
Family-focused treatment for Adolescents
Miklowitz, D., Axelson, D., Birmaher, B., et al. (2008). Family-focused treatment for adolescents with bipolar disorder. Archives of General Psychiatry, 65, 1053-61.