Transcript Child and Adolescent Psychopathology

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:
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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