Clinicians wishing to implement evidence-based pharmacological or psychotherapeutic treatment for their pediatric BD patients face a scarcity of data. The lack of replicated findings from randomized placebo-controlled trials, or trials comparing different psychotherapeutic approaches, precludes designating any treatment as having “strong” evidentiary support for treating pediatric BD. In the discussion below, we review separately psychopharmacological and psychotherapeutic interventions that show promise for treating pediatric BD.
PSYCHOPHARMACOLOGICAL TREATMENT
Medication is often the first intervention with a BD child, with the goal to provide an immediate reduction in symptom severity. Stabilization via medication may also better prepare the child to benefit from psychotherapeutic interventions (
Fristad et al. 2003,
Miklowitz et al. 2003a,
Pavuluri et al. 2004). Despite the widespread use of medication in youths with BD, there are few double-blind, placebo-controlled studies.
The AACAP practice parameters (
McClellan et al. 2007) recommend that treatment begin with either lithium or a medication approved by the FDA for BD in adults, such as anticonvulsants/mood stabilizers (e.g., valproate, divalproex, carbamazepine, topiramate, and lamotrigine), or atypical antipsychotics (e.g., olanzapine, quetiapine, risperidone, and aripiprazole) (
McClellan et al. 2007). A separate review of psychopharmacological treatment of BD youths recommends two algorithms, based on the presence or absence of psychosis (
Kowatch et al. 2005a). For the child with BD-I, manic or mixed, without psychosis, monotherapy with traditional mood stabilizers and atypical antipsychotics is advised, followed by combination therapy if there is a partial, or no response. When psychosis is present, the guidelines advise beginning with a combination of a mood stabilizer and atypical antipsychotic. With both algorithms, clozapine and/or electroconvulsive therapy are recommended as final treatment options if other medication trials fail.
In addition to the presence of psychosis, other considerations when selecting a medication include the youth's mood state, clinical variables (e.g., rapid cycling, comorbidities), risk of side effects, prior response to medication, and preferences of the patient and his/her family (
McClellan et al. 2007). Patients and their families must be educated about the risks associated with medication and the manner in which adverse effects may present themselves. In general, a six- to eight-week trial of a particular medication is required before an adequately informed decision can be made regarding changing or adding medications (
Kowatch et al. 2005b,
McClellan et al. 2007).
Chronic medication treatment may be required to prevent relapse in youths with BD. Noncompliance with lithium treatment was associated with a 90% relapse rate in adolescents; even those who were treatment adherent relapsed 38% of the time (
Strober et al. 1990). Thus, symptoms often fail to resolve on medication alone; rather, comprehensive treatment requires both psychopharmacology and psychotherapy.
PSYCHOTHERAPEUTIC TREATMENT
As with pharmacotherapy, there are few controlled studies of psychotherapy in BD youths. The AACAP practice parameters (
McClellan et al. 2007) and a prior report by
Goldberg-Arnold & Fristad (2002) suggest that psychotherapeutic interventions with BD youths should aim to improve (
a) the child and parent's understanding of the causes, symptoms, and treatment options of BD (psychoeducation); (
b) symptom management; (
c) coping skills; (
d) social and family relationships; (
e) academic and occupational functioning; and (
f) the prevention of relapse.
To these aims, a select number of interventions are beginning to demonstrate efficacy in treating young patients with BD. Treatment programs include child- and family-focused cognitive-behavioral therapy (CFF-CBT) (
Pavuluri et al. 2004), multifamily psychoeducation groups (MFPG) (
Fristad et al. 2002), and family-focused psychoeducational therapy (FFT) (
Miklowitz et al. 2000). Whereas CFF emphasizes individual psychotherapy with children and parents, parent training and support, and family therapy, MFPG uses child and parent group therapy, and FFT adopts a family-therapy format. Though these approaches differ somewhat in the extent to which they focus on individual treatment or incorporate group and/or family approaches, many of the therapeutic strategies and aims are shared across treatments.
At their core, these treatments incorporate basic tenants of psychoeducation, interpersonal therapy, and CBT to address the affective instability and psychosocial deficits in children with BD. Sessions initially focus on educating participants about BD symptoms, suspected neurobiological causes, medications, and systems of care. Psychoeducation must be developmentally appropriate to insure that children with BD fully comprehend the educational material. These treatments also take a cognitive-behavioral approach to helping BD youths better understand their emotions, thoughts, and actions, and learn the skills to regulate their affect and behavior, cope with distorted cognitions, and improve self-efficacy. Social dysfunction is targeted via social skill building, interpersonal problem solving, and perhaps most importantly, role-playing to learn to enact these skills in social situations.
Finally, improving family functioning is a primary goal of these interventions. Using behavioral rehearsal and role-playing, family members learn to reduce conflict and augment the positive nature of family interactions. Family interventions often focus on communication enhancement, including improving active listening skills, effective delivery of positive and negative feedback, and learning ways to seek changes in others' behaviors. An additional focus is improving problem-solving skills by learning how to appropriately define and label problems, brainstorm solutions, evaluate pros and cons of alternative solutions, identify the option most likely to be successful, and implement the identified solution (
Miklowitz et al. 2003b).
Initial studies support the efficacy of these psychotherapies in BD youths and their families. A 12-week course of CFF-CBT is associated with significant symptom reduction and improved overall functioning (
Pavuluri et al. 2004). A recent follow-up study of CFF-CBT using psychosocial booster sessions and optimized pharmacotherapy found that, over three years, intervention resulted in the maintenance of clinically significant improvements in affect and functioning; 83% of participants responded to treatment and were experiencing no or minimal symptoms (
West et al. 2007). The eight-session MFPG is associated with improvement in multiple domains, including increased knowledge about BD and ability to obtain appropriate services, overall improved family environment, more positive attitudes in both children and parents, and increased social support for BD children (
Fristad 2006;
Fristad et al. 2002,
2003). Finally, most studies with FFT have involved adult BD patients; these find improved compliance with medication treatment (
Miklowitz 1996) and one-year maintenance of significantly reduced depression and mania symptomatology (
Miklowitz et al. 2004). Recently, the completion of a two-year open trial of FFT and pharmacotherapy in adolescents resulted in significant reductions in mania and depression symptoms in youths and reduced negative parental behavior (
Miklowitz et al. 2006).
In addition to these treatments, interpersonal social rhythm therapy (IPSRT) (
Frank et al. 2000) may be applicable to pediatric BD patients. Based on data showing that changes in daily routine are associated with increased risk for mania and mood lability in BD adults (
Leibenluft et al. 1996), IPSRT seeks to minimize the effects of life stressors on individuals' schedules by helping the patient establish regular patterns of sleep, exercise, and social interactions. IPSRT in adults has been shown to be superior to intensive clinical management (e.g., supportive psychotherapy plus psychoeducation) (
Frank et al. 2005). There are no studies of IPSRT in youths with BD, but current research is studying a developmentally appropriate version of IPSRT for BD youths ages 12 to 18. This intervention targets interpersonal functioning, role transitions, regularity in sleep and social interactions, and family involvement (
Hlastala & Frank 2006).
Although these therapies show promise in treating pediatric BD, it is important to emphasize that these studies are uncontrolled, meaning these have yet to display efficacy in comparison with a randomly assigned alternate treatment. Research is currently underway to determine the extent to which these interventions differ from treatment as usual, wait-list controls, or other therapeutic approaches.
Which of these psychosocial interventions is ideal? A recent study of depressed BD adults suggests they may be equally successful. A randomized controlled study examined the benefits of four disorder-specific psychotherapies in conjunction with pharmacotherapy in depressed adult patients with BD I or II (
Miklowitz et al. 2007). Patients were randomly assigned either to collaborative care (N = 130), which consisted of a brief psychoeducational intervention, or intensive psychotherapy (N = 163), which consisted of either FFT, IPSRT, or CBT given weekly and biweekly for up to 30 sessions in nine months. Results found that the intensive psychotherapy was superior to collaborative care in terms of significantly higher year-end recovery rates and shorter times to recovery. Importantly, the three forms of intensive psychotherapies were comparable in their treatment efficacy. Given the extensive overlap in treatment goals, these results suggest that the active treatment component may be more important than the specific format used. Specifically, psychotherapeutic success with a BD patient is best achieved by improving the patient's knowledge of his disorder and providing him with skills to regulate his mood and behavior, better interact with peers, and better communicate and problem solve with family members. Given that this study was conducted with depressed BD adults, it is unclear if similar results would be seen in BD youths, in whom depressive states may be less common. An extension of this type of research to child and adolescent samples may delineate optimal components and potential developmental modifications of therapy for pediatric BD and determine if one form of psychotherapy is superior to another in youths with BD.
TREATING SEVERE MOOD DYSREGULATION
The above review informs treatment of youths with BD, but it is unclear the extent to which such strategies would achieve comparable efficacy in youths with SMD. Given that the above psychotherapies are nonspecific in the symptoms they target, it is possible that SMD youths would benefit from treatments that aim to improve family functioning and regulation of affect and behavior. At the same time, it is advisable that clinicians use psychotherapeutic treatments that are implicated with those DSM-IV disorders that are common in youths with SMD, namely ADHD and ODD. This is likely to include behaviorally oriented approaches, such as contingency management, clinical behavior therapy, and sociotherapy, which involve parental education and training (
Jensen 2000,
Steiner & Remsing 2007,
Wells et al. 2000). The extent of individual therapy will depend upon the developmental level of the child or adolescent. The typical principles involved in parent management training, the approach with strongest empirical support for disruptive behavior disorders in children, include reducing positive reinforcement of disruptive behaviors while increasing reinforcement of prosocial and compliant behavior, and the consistent and immediate application of consequences and/or punishment for disruptive behaviors (
Steiner & Remsing 2007). In addition, given the prominent mood disorders often seen in youths with SMD, incorporating cognitive-behavioral strategies proven effective in youths with depression and/or anxiety may be indicated (
Kendall et al. 2004,
Ryan 2005). As the study of SMD youths increases, incorporating investigation of research strategies will be of great benefit.
As with psychotherapy, the pharmacological treatment of SMD youths has not been studied systematically. Given the prevalence of ADHD in SMD, stimulant medications (
Jensen 2000) may be indicated for treating the hyperarousal symptoms seen in SMD. Although there is concern that stimulants may induce mania in BD youths or those at risk of developing BD (
DelBello et al. 2001,
Carlson & Kelly 2003), it is unknown if this potential risk extends to SMD youths. Data from the large Multi-Modal Treatment of ADHD study found that ADHD youths with severe irritability (e.g., comparable to SMD youths) responded positively to stimulants without increased risk for adverse responses, relative to youths with ADHD but without irritability (
Galanter et al. 2003).
Finally, given the prominent mood and anxiety symptoms seen in SMD patients, selective serotonin reuptake inhibitor (SSRI) antidepressants may be indicated, given their efficacy in treating depression and anxiety in youths (
Emslie et al. 2002). SSRI use is complicated by recent “black box” warnings and concerns of a potential risk for inducing mania in youths with BD (and perhaps SMD as well). However, the careful use of SSRIs in conjunction with mood stabilizers, especially when mood stabilizers are used first, may improve functioning in BD youths without an increased risk of mania (
Wagner 2004). Clearly, it is unknown the extent to which medications implicated for treating BD may be effective or harmful to SMD youths. Randomized controlled trials with SMD samples are required to understand what medications are indicated.