Download Session Eight - Parents Only

RAINBOW TREATMENT PROTOCOL
Child and Family Focused Cognitive Behavioral Therapy for Pediatric
Bipolar Disorder
RAINBOW can be implemented in a flexible manner with the sequence and tools outlined below
as an overall guide. We found that this sequence worked for most children and families seen at our clinic.
Sessions are typically scheduled twice weekly for the first six sessions and three times a week for the last
six sessions. Some flexibility is allowed in the frequency of visits especially if the families have to travel
long distances to attend therapy sessions.
Sessions One and Two - Parents and Child Together
The content of these sessions focus on helping the family understand the diagnosis and define the
problems using a common language acceptable to the child, family and therapist. Often children name their
illness in a creative way to encapsulate their experience, such as ‘invisible fist’ and ‘volcano.’ Discussion
also involves determining the "signature" or symptom profile of PBD that includes symptom severity,
cycling pattern, and timeline for that child. To develop a timeline, the parent is taught to complete a life
chart (Leverich & Post, 1995) and asked to complete it during the first month of therapy. Families are
encouraged to view PBD as a brain disorder that results in excessive reactivity and ‘wiring dysfunction’ in
the brain. Families are further informed about the role of medications and the value of adherence to
treatment. The complexity of comorbidity is explained along with written and verbal tips to manage
problems such as ADHD. An overview of the "RAINBOW" treatment is then provided.
During the first session, emphasis also is placed on establishing a "routine" and minimizing sleep
disruption. For children who are unable to self-sooth, progressive muscle relaxation, relaxation tapes, or
music are introduced and children are encouraged to use these strategies to decrease stress and facilitate
sleep. The importance of medications in achieving "affect regulation" is also discussed.
Session Three - Parents Only
The third session of RAINBOW focuses on teaching parents the specifics of affect regulation and
helping them bolster their view of themselves in the parental role. Parents are encouraged to use "I can do
it" self-statements and "No negative thoughts" to bolster helpful thoughts and overcome feelings of guilt
and inadequacy. They are trained to help their children use the same skills to which the child will be
introduced in subsequent sessions. The therapist describes the thought processes common to children with
PBD which include grandiosity, paranoia, and devaluing thoughts about self and others. To counteract such
dysfunctional thought processes, parents are encouraged to use logical thinking to re-orient their children
rather than directly confront the children about their misguided perceptions.
Sessions Four Through Seven: Child Only1
To enhance the child's understanding, the acronym “RAINBOW" is used to introduce the concept
of affect regulation. The therapist encourages the child to share his or her perceptions of RAINBOW as
well as thoughts and feelings associated with it. These could emerge as aggression, irritability, elation,
depression, feeling "goofy," or feeling "out of control." The child is asked to monitor his/her moods daily
by way of a mood chart. The therapist explains how difficult feelings or emotions (reactivity) are related to
maladaptive behaviors. To help the child cope with mood swings or affect regulation more effectively, the
therapist encourages the child to recognize difficult emotions and use self-talk as a way to counteract them.
Recognizing the "triggers" of anger and excitability is a key component of these sessions. Children
(and parents, if present) are taught the A-B-C model of antecedent feelings or triggers, behavior, and
consequences. Children are given an opportunity to talk about a personal situation using the A-B-C model
and provided strategies to generate positive self-talk or cognitive self-statements. Whenever the child feels
uncontrollably excited or angry during upcoming weeks, parents are encouraged to ‘walk’ their child
through the A-B-C model.
Using the same principles for restructuring cognitions, the therapist fosters further skills in helping
children say “I can do it” and “no negative thoughts.” Children are encouraged to develop stories about
their talents and are assisted in developing a strong belief in their strengths. Children are next encouraged
to write or tell a “sad story,” for example, about how no one will sit with them at lunch. Children and
therapist then work together to rewrite the “sad story “ to make it a “happy story.” Principles of
interpersonal psychotherapy and CBT intersect here as children practice new ways of looking at themselves
at the same time they are learning to modulate their behavior to improve interpersonal relations.
Session Eight - Parents Only
Central to the topic of joint problem solving, parents are taught effective communication
techniques and ways to cope with their child's illness. These strategies include gaining a genuine
understanding of their child and learning to accept their child's illness and refrain from quick judgments. To
create opportunities for healthy conversations, parents are encouraged to ask their children questions on
what, when and how their day went or how an activity was at school or in the neighborhood. Other
communication skills covered include active listening and validating the child’s feelings. Another way to
avoid friction is for parents to offer children choices.
Parents are also provided metaphors as ways to understand their children's behaviors. For
example, parents are encouraged to view an explosive rage as a fire - No one should touch a flame or it will
burn their hands. Therefore, they need to leave the fire alone until the embers cool. Once the child is
calmer, parents can discuss an event with the child in a more rational way and find better solutions based
on compassion. The "flame-like outbursts" are reframed as symptoms of the illness rather than incidents of
intentionally "bad" behavior. Parents are taught how to give feedback and provide negative consequences
in ways that are meaningful and beneficial to the child.
Sessions Nine - Parents and Siblings Together
There are three essential elements to be covered during this session. First, siblings are asked to
ventilate their difficulties with regards to their affected sibling and have their feelings validated by the
therapist. Second, the therapist explains the intensity and impact of PBD on the affected child to help the
siblings gain a better understanding of the disorder and develop empathy. Third, siblings are taught how to
act assertively and to disengage from direct confrontations by the affected sibling.
Parents are also encouraged to watch the therapist at work and role-play how siblings can respond
to the patient’s provocations. Such interventions serve to assist siblings in generalizing newly learned
coping skills to the home environment.
Sessions Ten and Eleven - Child and Parents Together
During these sessions, the therapist problem solves with parents about common life stresses faced
by their child with PBD and other members of the family. Children are encouraged not to react to trigger
situations in a "knee jerk" fashion, but to "react smart" by thinking and problem solving.
Session Twelve - Child and Parents Together
Two goals are to be accomplished during this final session. The first goal is to reinforce strengths.
Children and parents are encouraged to identify the special abilities they have recently recognized along
with pleasant experiences in their lives. These are considered the content of the family's “goodie bag of
treasures” to review and recollect when feeling sad. The therapist reminds family members not to focus on
problematic situations or let unhelpful thoughts take over.
The second goal of this session is to help family members find “ways to get support.” Children
and parents are encouraged to talk about special people in their life and how they can enlist their support
network to help them recover from depression or rage attacks. Family members are reminded that asking
for help is a sign of strength and ways to seek help are then role-played. A support tree with the names of
all the identified members of the family's support network is then drawn and reviewed.
School Component of RAINBOW
A standard component of RAINBOW involves school liaison and psycho-education for school
personnel. It has been our experience that the typical child with PBD manifests significant interpersonal
and academic problems at school. Teachers and other school personnel are greatly challenged by the
intensity and unpredictability of the child's behaviors. As a result, it is often critical to the child's recovery
that the therapist educates school personnel about the illness and provides them with specific information
and strategies they can use to address the child's educational needs. As part of the RAINBOW
protocol and with parental consent, therapists will initiate contact with school personnel early in the child's
treatment to discuss school issues. In addition, teachers are provided with a portfolio of RAINBOW
materials. If the illness significantly impacts educational progress, children with PBD may be eligible for
individualized accommodations under Section 504 or special education services under the category of
"Seriously Emotionally Disturbed" (SED). To facilitate such support, the therapist would send a letter to
the child's school that includes information about the diagnosis, ways in which the disorder interferes with
the child's performance in school, and recommendations for accommodations to the child's educational
program. Parents are also provided a copy of a sample Individual Education Plan (IEP) for a child with
PBD (Andersen et al., 2003). We found that a teleconference between the therapist and school personnel at
the time of the IEP conference is critical and facilitates the initiation of needed services.