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Chapter 11: Bipolar Disorders Amy E. West Amy T. Peters Overview Bipolar spectrum disorder is diagnosed based on the presence of episodes of either extreme irritability or elevated, expansive mood in combination with other symptoms that include: Grandiosity Decreased need for sleep Hypersexuality Depressed mood Racing thoughts Impulsive behavior Compared to the typical adult presentation of bipolar, children with pediatric bipolar disorder (PBD) tend to experience longer episodes with rapid cycling patterns and symptoms of mixed mood states Neurological Underpinnings of PBD Demonstrate impairments in cognitive domains associated with learning, problem solving, and cognitive/emotional modulation: Attention Working memory Executive function Verbal memory Processing speed Impairments persist over time Occur independent of mood state Impairment in Functioning Psychosocial functioning Individual, family, peer, school/community Academic underperformance Problems in math and reading, disruptive school behavior Peer relationships Limited peer networks, peer victimization, poor social skills Family functioning Strained sibling and parent relationships Less warmth, affection, and intimacy More fighting, forceful punishment, and conflict Severity of Symptoms Children with PBD experience high rates of repeated hospitalizations and suicide attempts (Leinsohn et al., 2005) In adulthood, PBD patients demonstrate greater mental health care utilization, elevated rates of other chronic disease and health conditions, lower rates of school graduate, and loss of workdays and career productivity (e.g., Kessler et al., 2006) CFF-CBT Child- and family-focused cognitive-behavioral treatment (CFF-CBT) Family-focused psychosocial intervention Children ages 7–13 Integrates cognitive-behavioral approaches with psychoeducation, interpersonal psychotherapy, mindfulness, and positive psychology techniques 12 weekly sessions: some child-only, some parent-only, but most are family sessions Psychoeducation Multifamily group sessions Children ages 8–12 with bipolar and depressive spectrum disorders Goal of intervention is to teach parents and children about: Child’s illness Symptom management Problem-solving and communication skills Coping skills Providing support for the parents FFT-A Family-Focused Treatment for Adolescents (FFT-A) Aims to reduce symptoms and increase psychosocial functioning through an increased understanding about the disorder and coping skills, decreased family conflict, and improved family communication and problem solving 21 individual sessions over 9 months Three components: psychoeducation, communication enhancement training, and problem solving DBT Dialectical Behavior Therapy (DBT) for Adolescents Targets emotional instability over the course of 1 year Two modalities: family skills training (delivered to whole family) and individual psychotherapy for the adolescent Acute treatment phase: 6 months, 24 weekly sessions Continuation treatment: 12 additional sessions tapering in frequency over the rest of the year IPSRT-A Interpersonal and Social Rhythm Therapy for Adolescents (IPSRT-A) Targets circadian rhythms and neurotransmitter systems because of their known vulnerability as precipitants for mood episodes Aims to stabilize social and sleep routines, address interpersonal precipitants to dysregulation (e.g., interpersonal conflict, role transitions) Primarily individual treatment, but does incorporate brief family psychotherapy Parent Involvement PBD places large burden on families of affected children Families of bipolar children report: Low levels of cohesion Low levels of expressiveness Low levels of family activity High levels of family conflict Unstable family dynamics associated with adverse treatment outcomes (Townsend et al., 2007) Parent Involvement in Treatment Core of family involvement is psychoeducation Important for family to develop an understanding of PBD and the impact parent and family systems have on its course of illness Parents educated on: nature of mood episodes, risk factors and comorbidity, role of medications in treatment, how to monitor safety and side effects, and how to navigate the mental health care and educational systems Additional components: boost parenting efficacy, provide parents support, and help them cope with managing their child’s illness Shared Goal Existing psychosocial interventions for PBD share the important goal, independent of their particular theoretical orientation, of establishing a family context that facilitates long-term recovery Children with PBD are extremely vulnerable to negative psychological and psychosocial problems Primary caretakers play critical role in buffering against negative outcomes Existing family-based models indicate parent and family involvement is essential ingredient in PBD treatment Adaptations and Modifications Even the best evidence-based, targeted, and comprehensive manualized interventions cannot be applied to patients in a one-size-fits-all manner NIMH Strategic Plan: promote “personalized” medicine PBD has significant heterogeneity in symptom presentation, high rates of comorbidity, incidence of parent psychopathology, and observed challenges in the family system Likely that manual-based interventions need to be flexibly implemented Measuring Treatment Effects Currently no child-specific DSM criteria for PBD Although it is recognized that there are differences in symptom presentation between adults and children Development of measures to assess for mania have increased of the past few years, but vary widely in terms of content, reading level, and validation Young Mania Rating Scale (Young et al., 1978) Children's Depression Rating Scale-Revised (Poznanski et al., 1984) Difficulties With Measurement Measuring treatment effects in PBD is complicated by cross-informant issues Information regarding child symptoms and behavior is generally collected from three sources: caregiver, teacher, and child Greatest validity is in parent report, even when the parent has a diagnosed mood disorder (Youngstrom et al., 2006) Children tend to underreport the severity of their mood symptoms (Youngstrom et al., 2004) Clinical Case Example: Maggie 9 years old Lived at home with biological parents and 13 year old brother Referred to the CFF-CBT/RAINBOW therapy program Initial assessment: structured clinical interview and mood symptoms rating scales (parent, child, and clinician-reports) Diagnosis: Bipolar I Disorder Symptoms Frequent irritability, mood liability, intense periods of anger or “rage attacks” History of periods of elated or giddy moods with increased energy, increased activity in several areas, motor hyperactivity, reduced sleep, and racing thoughts Often followed by increased in irritability and depressed mood Treatment Maggie attended treatment with her mother Father attended parent-only and family sessions when he could Phase I: engaging the family in the treatment process and identifying goals Phase II: focused on Maggie’s affect dysregulation and the management of rage episodes Phase III: understanding and managing family and environment stressors that contributed to stress and poor coping Outcomes Maggie demonstrated greater insight into her symptoms, self-esteem, and ability to cognitively reframe her angry thoughts Increasingly able to use her coping skills independently and prevent her anger from escalating Maggie’s parents became increasingly proficient in their ability to recognize warning signs of distress and help soothe Maggie early on to prevent further escalation