BIPOLAR CHILDREN PART 1: PSYCHOSOCIAL TREATMENT
From Mood Disorders in Children and Adolescents, presented by the Nemours Alfred I. duPont Hospital for
Children, Wilmington, Delaware
David J. Miklowitz, PhD, Professor of Psychology and Psychiatry, University of Colorado, Boulder, and Health
Sciences Center, Denver
| Introduction: most work on bipolar disorder done on adults, literature on children and adolescents scant; several
groups, including speaker’s, considering how adult therapies can be applied to children and adolescents; although
medication essential to treatment of bipolar disorder, psychotherapy necessary adjunct; in 1989, National Institute
of Mental Health (NIMH) observed, “perhaps the most underdeveloped area in the treatment of bipolar disorder
is the use of adjunct psychosocial therapies”
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| When treated with pharmacotherapy alone: adult and pediatric patients still have slow time to recovery and
high rates of recurrence; poor school, work, and social functioning; high rates of suicide risk; high rates of service
utilization; difficult environmental circumstances that provoke recurrences; significant family disruption; medication
noncompliance
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| Medication noncompliance: recent study by managed care organization showed that average time on lithium 76
days; in another study, 31% of bipolar children and adolescents failed to comply with any mood stabilizer over 6-wk
period (“now imagine what it’s like to keep the kid on it for 6 to 12 mo”); predictors of noncompliance include younger
age, male sex, missing high periods, severe illness, low socioeconomic status, substance misuse, lack of family support,
and lack of information about bipolar disorder
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| Psychosocial stressors: truism that bipolar episodes are precipitated by psychosocial stressors such as high levels
of conflict in families, high levels of criticism, hostile interactions, negative overprotection, lack of boundaries, and
enmeshment; life events that disrupt sleep-wake cycles associated with manic episodes; also, “bipolar disorder is
one of the few illnesses that can be precipitated by a good thing happening”; some evidence that early physical and/
or sexual abuse may be precipitant of adult-onset bipolar disorder in people with genetic vulnerability
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| Common ingredients of psychosocial therapies for bipolar disorder: encouraging patient to collaborate in
own treatment; educating patient about bipolar disorder; fostering patient’s acceptance of illness and of its necessary
treatments; reducing trauma associated with bipolar disorder; encouraging medication compliance and ongoing
collaboration with physician; monitoring mood symptoms daily; enhancing relationships with caregiving
relatives; promoting good sleep hygiene, especially in response to stressors; teaching patients and relatives to recognize
warning signs of new episodes and to develop relapse-prevention plans; teaching patient to manage life circumstances
that surround his or her illness; reengaging patient with his or her social and occupational milieus;
evaluating and challenging assumptions about bipolar disorder, its future course, and its treatments; providing nonspecific
therapeutic support; conveying empathy and optimism; recognizing patient’s need for autonomy and control
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| Psychosocial interventions: several available, including interpersonal and social rhythm therapy (IPSRT), cognitive
behavior therapy (CBT), group psychoeducation, multi-family psychoeducation groups (MFPG), and family-
focused therapy (FFT); results usually not seen immediately, but become apparent over time (clinical benefits
sometimes not seen for 6 to 9 mo)
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| Interpersonal and social rhythm therapy: key is getting bipolar patients to regularize daily routines; uses Social
Rhythm Metric to monitor daily routines and moods; incorporates interpersonal therapy (IPT) to explore link
between mood and life events, to focus on interpersonal problem areas, and to allow patient to grieve for lost
healthy self; in study, using IPSRT in acute phase of bipolar disorder led to significantly longer survival (ie, interval
without new mood episode) in maintenance phase, and participants in IPSRT had significantly higher regularity
of daily routines; in addition, ability to increase regularity of daily routines in acute phase associated with reduced
risk for new mood episode in maintenance phase
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| Cognitive therapy: most familiar model posits that certain life events generate dysfunctional, negatively biased
thoughts, which in turn can lead to depression; more complicated model posits that life events lead to automatic
thoughts, which results in patient extrapolating data from environment consistent with his or her negative self-image
and in development of core dysfunctional beliefs that interpret future events negatively, all of which can lead to depression;
components of CBT—psychoeducation following diathesis-stress model; cognitive behavioral skills that
help to monitor mood and prodromes and to modify sleep behavior; recognizing importance of adhering to daily routine
and of getting adequate sleep; dealing with long-term vulnerability issues; study showed that at 12-mo follow-up,
60% of patients who received CBT plus medication had not had recurrent episode, whereas “almost everybody” who
received only medication had; components of CBT adapted for bipolar children and adolescents—
psychoeducation; setting treatment goals; encouraging medication compliance and mood monitoring; identifying
stressors; problem solving; checking in with parents; identifying and challenging negative thoughts; regulation of
sleep; relaxation techniques; assertiveness training; improving family communication; preventing relapses
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| Psychoeducation: psychoeducation is feature of every form of psychotherapy for bipolar disorder, but some models
focus exclusively on teaching, including teaching patients how to manage disorder, how to recognize early
warning signs of recurrent episode, and why medication necessary; individual psychoeducation model for adult bipolar
patients developed in Britain emphasized identification of prodromal symptoms; patients attended 7 to 12
sessions focused on producing and rehearsing action plan (including plans for seeking treatment) and recorded
plans on laminated card that they could refer to as needed; over 70 wk, rates of manic relapse in psychoeducation-
plus-medication group 30% to 35% and in control group (medication only) 60% (no effect found on depression)
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| Group psychoeducation: Spanish study organized euthymic patients into groups of 8 to 12 patients who attended
21 sessions of 90 min each; focused “very heavily on managing the illness”; at 24 mo, rate of recurrence lower but
rate of dropout higher in psychoeducation group than in control group
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| Expressed emotion: refers to critical, hostile, or emotional overinvolvement among caregiving relatives; measured
when patient acutely ill, and high expressed emotion strong predictor of patient having recurrence within 1 yr,
whereas low expressed emotion produces about 50-50 chance of recurrence within 1 yr; criticism—often straightforward;
examples include “I don’t like it when he stays out late at night” and “I resent his poor-me attitude”;
hostility—more personal; examples include, “I wish he’d never been born” or “I hate him”; emotional
overinvolvement—trickier to recognize because appropriate level of protectiveness varies with patient’s age and
abilities; speaker’s study—found relative’s statements related to extent relative believes patient’s behavior volitional;
for example, relative who believes patient can control behavior might say, “this is just the kind of person he
is; he’s irritable because he’s an angry person,” while relative who recognizes that patient has illness might say,
“he’s irritable because that’s the way bipolar people are”
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| Family therapies: include MFPG studied at Ohio State University; 8 sessions of 90 min each; initially, parents and
children together, but later separated into parents’ groups and children’s groups; children given education about bipolar
disorder and training in social skills; families given projects to work on together at home; patients in families
that received family therapy had drop in mood-severity score from 30 to 20, while control group (people on waiting
list) showed no change
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| Family-focused therapy: speaker’s program; consists of 21 outpatient sessions over 9 mo; initial session assesses
patient and family for expressed emotion and interactional behavior; program consists of 3 components: 1) psychoeducation,
including how to recognize symptoms and early warning signs (families can often identify early
warning sign of recurrent episode when patient or therapist cannot) and importance of medication compliance
(“this is a family problem because adherence is a very emotional issue; it’s not just an issue of lack of information;
it’s also an issue of establishing boundaries between people and various beliefs that people hold about medications”);
2) training in enhancing communications; and 3) training in problem-solving skills; for example, how
can child be reintegrated into social milieu? how will he or she interact with school system? how can he or she
regain friendships that have been lost? how can he or she regulate sleep-wake cycle? how can he or she stay on
medications?
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 | Core themes of FFT: integrating family’s experiences of mood disorder; understanding vulnerability to future episodes;
accepting necessity of psychotropic medication; distinguishing patient’s personality from his or her disorder;
recognizing and coping with stressful events that might trigger recurrences; reestablishing functional family
relationships after recurrent episode
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| Studies: first study involved 101 adults in acute manic, mixed, or depressive episode; 80% started study when hospitalized;
randomly assigned to FFT or to crisis-management therapy; patients in FFT survived without recurrence
for average of 73.5 wk, compared to 53 wk in control (crisis-management) group; all patients had increase
in symptom severity at ≈3 mo, then patients in FFT group began to stabilize at lower level of symptom severity;
complete compliance with medications 45% in FFT group vs 21% in control group (but two thirds of all patients
noncompliant at some time); improvement seen in depressive symptoms, indicating improvement in medication
compliance, but also perhaps improvement in “something about the social environment and family climate”
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| Other studies: one compared FFT to individual psychoeducational therapy and found results for FFT more favorable;
another applied FFT to adolescents and found results favorable
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| Conclusions: 1) course of bipolar disorder strongly influenced by stress; 2) many bipolar patients have better outcomes
when psychosocial factors incorporated into their assessment and treatment; 3) effects of psychosocial treatment
and pharmacotherapy may be synergistic; 4) psychosocial treatments may enhance medication compliance; 5)
how can family be incorporated into treatment of younger bipolar patients (ie, what are mechanics of incorporating
family into treatment? what problems arise? what kinds of resistance? what kinds of questions do families have?
what are good and bad ways of addressing these questions?)
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| 1. How to deal with fact that bipolar disorder familial and psychiatric problems may be seen in parents and siblings
of patient? bipolar child often feels singled out and “like they’re in the hot seat,” and knowing that other family
members also have psychiatric problems can help child to cope with his or her illness; encourage family members
to talk about their experiences and explore whether they can help patient understand problems he or she has
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| 2. Should adults be advised to seek separate treatment for their psychiatric problems? yes; however, they may already
be in treatment when presenting for family therapy for bipolar child
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| 3. Are seasonal changes seen in bipolar patients? And what should be done about it? yes, seasonal changes seen in
speaker’s practice in Colorado, which has seasonal changes that are sometimes dramatic; he sees increase in depression
and mania, and unable to account for increase in mania; patient known to have seasonal depression
may benefit from addition of adjunctive medication during fall and winter; also light treatment, walks in sun,
and exercise can be effective adjuncts
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| 4. What is role of hormones in bipolar disorder? speaker has not seen “convincing evidence” that hormones play role
in bipolar disorder, although he has seen several girls whose symptoms stabilized with birth control pills, “but in
more cases than not it doesn’t pan out very well”
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| 5. What role does kindling play in bipolar disorder? some evidence supports theory that kindling plays role and
some evidence refutes it; University of Iowa has some evidence that rapid cycling or kindling, if they do occur,
occur in discrete period, then go away; both sometimes associated with antidepressant; speaker thinks
kindling may occur in some patients but not in others
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Educational Objectives
| The goal of this program is to educate the listener about the treatment of bipolar disorder in children and adolescents.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Explain the role of psychosocial stressors in triggering bipolar episodes.
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| 2. Discuss the advantages of adding psychosocial interventions to pharmacotherapy for bipolar disorder in children
and adolescents.
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| 3. Describe several types of psychosocial therapies that can be of benefit in the treatment of bipolar disorder.
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| 4. Define “expressed emotion” and discuss how it affects the prognosis of a child or adolescent with bipolar disorder.
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| 5. Evaluate family-focused therapy for children and adolescents with bipolar disorder.
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Suggested Reading
Colom F et al: A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar
patients whose disease is in remission. Arch Gen Psychiatry 60:402, 2003; Colom F et al: Clinical factors associated
with treatment noncompliance in euthymic bipolar patients. J Clin Psychiatry 61:549, 2000; Frank E et al:
Two-year outcomes for interpersonal and social-rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry
62:996, 2005; Frank E, Swartz HA, Kupfer DJ: Interpersonal and social-rhythm therapy: managing the
chaos of bipolar disorder. Biol Psychiatry 48:593, 2000; Frank E: Treating Bipolar Disorder: A Clinician’s Guide
to Interpersonal and Social Rhythm Therapy, New York: Guilford Press, 2005; Fristad MA, Goldberg-Arnold
JS, Gavazzi SM: Multi-family psychoeducation groups in the treatment of children with mood disorders. J Marital
Fam Ther 29:491, 2003; Geller B et al: Two-year prospective follow-up of children with a prepubertal and early
adolescent bipolar disorder phenotype. Am J Psychiatry 159:927, 2002; Jamison KR, Gerner RH, Goodwin
FK: Patient and physician attitudes toward lithium: relationship to compliance. Arch Gen Psychiatry 36(8 Spec
No):866, 1979; Jamison KR: An Unquiet Mind: A Memoir of Moods and Madness, New York: Knopf, 1995;
Johnson SL et al: Social support and the course of bipolar disorder. J Abnorm Psychol 108:558, 1999; Kowatch
RA et al: Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder.
J Am Acad Child Adolesc Psychiatry 39:713, 2000; Lam DH et al: A randomized controlled study of cognitive
therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Arch Gen Psychiatry
60:145, 2003; Malkoff-Schwartz S et al: Stressful life events and social-rhythm disruption in the onset of manic
and depressive bipolar episodes: a preliminary investigation. Arch Gen Psychiatry 55:702, 1998; Miklowitz DJ et
al: A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of
bipolar disorder. Arch Gen Psychiatry 60:904, 2003; Miklowitz DJ et al: Family factors and the course of bipolar
affective disorder. Arch Gen Psychiatry 45:225, 1988; Miklowitz DJ, Goldstein MJ: Bipolar Disorder: A Family-Focused
Treatment Approach, New York: Guilford Press, 1997; Miklowitz DJ: The Bipolar Disorder Survival
Guide, New York: Guilford Press, 2002; Perry A et al: Randomised controlled trial of efficacy of teaching patients
with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ 318:149, 1999; Prien RF,
Potter WZ: NIMH workshop report on treatment of bipolar disorder. Psychopharmacol Bull 26:409, 1990; Rea
MM er al: Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical
trial. J Consult Clin Psychol 71:482, 2003; Simoneau TL et al: Bipolar disorder and family communication: effects
of a psychoeducational treatment program. J Abnorm Psychol 108:588, 1999; Strakowski SM et al: Twelve-
month outcome after a first hospitalization for affective psychosis. Arch Gen Psychiatry 55:49, 1998; Vaughn C,
Leff J: The measurement of expressed emotion in the families of psychiatric patients. Br J Soc Clin Psychol 15:157,
1976; Weiss RD et al: Medication compliance among patients with bipolar disorder and substance use disorder. J
Clin Psychiatry 59:172, 1998; Wendel JS et al: Expressed emotion and attributions in the relatives of bipolar patients:
an analysis of problem-solving interactions. J Abnorm Psychol 109:792, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Miklowitz reported nothing to disclose.
Dr. Miklowitz was recorded at Mood Disorders in Children and Adolescents, presented November 15, 2005, in
Wilmington, Delaware, and sponsored by the Nemours Alfred I. duPont Hospital for Children. The Audio-Digest
Foundation thanks Dr. Miklowitz and the Nemours Alfred I. duPont Hospital for Children for their cooperation in the
production of this program.
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