Pediatric bipolar disorder (PBD) is a chronic and debilitating illness characterized by mixed mood states, rapid cycling, excessive elation, prominent irritability, and frequent comorbid conditions (Birmaher et al., 2002
; Findling et al., 2001
; Geller et al., 1998a
; McClellan et al., 1999
; Wozniak et al., 1995
). These symptoms are associated with substantial disruption in psychosocial and family functioning, including difficulty in peer relationships, school problems, poor sibling relationships, parent-child relationships characterized by frequent hostility and conflict, ineffective problem solving, and poor agreement on parenting strategies (Geller et al., 2000
; Goldstein et al., 2009
; Schenkel et al., 2008
). The multitude of psychosocial impairments associated with PBD has led to consensus that psychosocial treatment adjunctive to medication is an important ingredient of comprehensive treatment for PBD (McClellan, Kowatch, & Findling, 2007
). Despite this recognition, however, evidence-based psychosocial treatments for children with bipolar disorder are relatively few in number (i.e. Fristad et al., 2002
; Miklowitz et al., 2008
Child and family-focused cognitive-behavioral therapy (CFF-CBT) is an adjunctive psychosocial intervention designed to meet the developmental needs of children aged 8–12 with bipolar disorder and their families (Pavuluri et al., 2004b
; West et al., 2007
). CFF-CBT comprises four innovative aspects in the treatment of PBD. It is developmentally specific to children aged 8–12; it is driven by the specific needs of these children and their families; it involves intensive therapeutic work with parents parallel to the work with children in a unique family-based model; and it integrates psychoeducation, cognitive-behavioral therapy, and interpersonal therapy techniques across multiple domains to address the impact of PBD in the child’s broader psychosocial context. To our knowledge, there is no other psychosocial treatment for PBD that combines these components in the same way. CFF-CBT is a 12-session treatment program delivered weekly over the course of three months, with the goal of improving symptomatic functioning, as well as increasing psychosocial and family functioning. Initially developed for an individual psychotherapy format, we modified the program to a multi-family group format in recognition of the enhanced parental support and information exchange that would likely occur in this setting, as well as the opportunity for children to practice interpersonal skills and have positive social experiences through group work. CFF-CBT is nicknamed “RAINBOW” treatment for its 7 main ingredients (for session details see ). The treatment ingredients and content are identical to the individual therapy format, but delivered in 2 parallel parent and child groups. Previous open trial research has indicated that CFF-CBT in its individual format is feasible, acceptable, and may result in symptom and functional improvement (Pavuluri et al., 2004b
); this study represents the preliminary open trial of the treatment in its group format.
CFF-CBT Group Session Objectives
Aspects of psychosocial functioning may be important outcome indicators of quality of life, as well as potential mediators between the intervention and traditional indicators of treatment response such as symptom management and treatment adherence. To date, there are few studies that have examined specific psychosocial variables as outcomes and/or mediators in psychosocial treatment studies for children and adolescents with bipolar disorder. Fristad and colleagues (2006)
reported findings from studies on their multi-family psychoeducation group (MFPG) treatment for PBD that indicated participation in MFPG was associated with changes in knowledge about the disorder, coping skills, and social support, as well as improved family interactions and positive attitudes in young children with bipolar disorder and their families. Findings reported by Miklowitz and colleagues (2006)
on their family-focused treatment (FFT) for adolescents with bipolar disorder suggested a potential mediating role for maternal expressed emotion and chronic life stress in treatment effects. Studies such as these are important because they represent initial explorations of how psychosocial interventions may operate over the course of treatment to affect both symptom-related and functional outcomes. Continued work in this area will contribute to the dismantling of psychosocial treatments, aid in the identification of key treatment ingredients, and enable the development of optimally efficacious, yet practical and efficient psychosocial treatment models.
In light of the limited number of evidence-based psychosocial approaches to the treatment of PBD, and the scarcity of knowledge on how psychosocial treatment directly influences potentially important functional outcomes, the objectives of the current study were three-fold. First, as this study comprised the preliminary open trial pilot study of group CFF-CBT, the primary objective was to establish the feasibility and acceptability of the treatment as delivered in its group format. Second, because of the potential importance of psychosocial factors both as important key outcomes related to quality of life, as well as potential mediators in treatment outcome, the secondary objective was to collect pilot data on psychosocial factors related to PBD, in addition to assessing improvement in symptomatic functioning. Child’s global psychosocial functioning, parenting stress, and parent’s knowledge and self-efficacy related to coping with PBD were chosen as the psychosocial outcomes of interest in this study because we believe these domains could represent barriers to achieving optimal treatment response if not addressed adequately. Third, to inform our future studies on treatment mechanisms, we examined the relation between parent functioning at post-treatment (parent’s stress, knowledge, self-efficacy) and children’s symptom experience and improvements in psychosocial functioning post-treatment, to explore the potential for parent functioning to mediate child outcomes. Thus, the study hypotheses were that: (1) CFF-CBT group treatment would be feasible to deliver and acceptable to families; (2) CFF-CBT group treatment would be associated with symptom improvements, as well as improvements in child’s psychosocial functioning, parenting stress, and parental knowledge and self-efficacy related to coping with the disorder; and (3) improvements in parenting stress, knowledge about PBD, and sense of efficacy in managing symptoms and coping with the disorder, may relate to improvements in children’s symptom experience and psychosocial functioning.