PSYCHOEDUCATIONAL TREATMENT FOR SCHOOL-AGED CHILDREN WITH BIPOLAR DISORDER

Method Participants.Thirty-four families with children aged 8 to 11 were screened for participation within a 6-month period. Of these, 28 (82%) passed the screen and came to the baseline assessment. Of these, 20 (71%) met studyinclusion criteria. Recruitment resources included psychologist 40%, media 35%, psychiatrist 10%, school counselor 5%, library Poster 5%, and another clinical trial 5%. Most children were male 85%, consistent with other studies of prepubertal BPD Gelleret al., 2000; Pavuluri et al., 2004 and Caucasian 90%!. Half of the households included married biological parents, 10% had married stepparents, and one family included married adoptive parents. Single biological parents accounted for 30% of the sample, and one fam-ily had a single adoptive parent. Incomes were widely distributed, with 20% below $39,000, 40% between $40,000 and $79,000, and 40% over $80,000. Many families 40% traveled from rural or geographically remote areas to participate participants average roundtrip: M6SD 70670 miles, range 14344 miles. Primary mood disorder diagnoses included 40% bipolar I disorder 10% manic type, 30% mixed type ; bipolar II disorder 35%; bipolar disorder, not otherwise specified BP-NOS: 25%. Children were, on average, impaired a considerable length of timemanic episode,M482.2 days,SD880.2; MDD, M 73.5 weeks,SD 121.8; and depressive episode,M 85.3 weeks,SD 145.7. Most 95%!had comorbid behavior disorders; a majority 70% had comorbid anxiety disorders. Family history was significant for BPD. Deleting from the analyses one adopted child for whom biological family history data were unattainable, 53% children had first-and0or seconddegree relatives with BPD; 79% had first and or second degree relatives with de-pressive disorders; and 84% had first and or second-degree relatives with BPD and0or de-pressive disorders. Seven families dropped out before study completioni, the 18-month follow-up!, four IMM families two completed treatment, two did not and three WLC families~none com-pleted treatment. Study dropouts were not statistically different from study completers on baseline demographic and clinical variables. Given the studys small sample size, theoccurrence of a few unfortunate events e.g., family illness, out of state move! had a relatively high impact. In addition, due to the small budget for this study, participant compensation for completing followup assessments was limited. Two IMM families dropped out after five IFP sessions, one because of scheduling problems after the mother returned to fulltime employment, and one after the IFP ther-apist reported bruises on the child to Childrens Services. BetweenT2 6-month followup and T3 12-month follow-up!one IMM and three WLC families discontinued participation in the studies, which was due to diagnosis and treatment of cancer in a family member, the child moved out of state to live with relatives, a mothers concern that participation would disrupt her childs current stable mood, and a family who did not return scheduling phone calls or letters. Between T3 and T4, one IMM family did not return phone calls or letters requesting they schedule an assessment.

Measures At the initial assessment T1, comprehensive family, developmental, medical, social, and school histories were taken, along with a mood lifeline see Quinn & Fristad, 2004, for a description of this procedure and a brief intelligence test Kaufman Brief Intelligence Test; Kaufman & Kaufman, 1990! to determine study eligibility and to demarcate clearly the onset, duration, severity, impairment, and off-set of mood symptoms during the childs life. Structured interviews, the Childrens Inter-view for Psychiatric SyndromesChild and Parent Forms child: Weller, Weller, Rooney, & Fristad, 1999a; parent: Weller, Weller, Rooney, & Fristad, 1999b!were administered to the parent and child separately to assess mood and comorbid DSM-IV American Psy-chiatric Association, 1994 psychopathology. Severity of mood impairment was rated using the Childrens Depression Rating Scale Revised CDRS-R; Poznanski et al., 1984 and the Mania Rating Scale MRS; Young, Biggs, Ziegler, & Meyer, 1978.A Mood Severity Index MSI was calculated to determine overall mood severity. TheMSI was calculated using the formula CDRS-R score 17 11017 MRS, which adjusts for differ-ing minimum scores CDRS-R 17, MRS and for the greater number of items on the CDRS-R. In addition, because both scales rate irritability, its rating was downweighted by 0.5 on each scale. Families utilization of medication, therapy, and schoolfocused services were measured by the Medication Usage Grids and the Mental HealthGrids Goldberg Arnold & Fristad, 1999; Davidson, Fristad, & Goldberg Arnold, 2006, whichwere given to the primary caregiver at each time period. These grids are semistructured interviews designed to record and rate service utilization. The preceding information was presented at an initial case review to determine study eligibility i.e., presence of a bipolar spectrum disorder. If eligible, the participants assessment data were then reviewed independently by two licensed psychologists, well acquainted with BPD, to determine the specific bipolar diagnosis. Following this independent review, a consensus conference was completed to fi-nalize mood diagnoses and to determine a global rating of treatment utilization i.e., med-ication, therapy, school, and other miscellaneous services. Additional instruments were administeredat the baseline assessment, but not reviewed at the initial case review or consensus confer-ence. One of these, the Expressed Emotion Adjective Checklist EEAC; Friedmann & Goldstein, 1993, assessed family EE. Finally, the Therapy Evaluation Parent and Child Forms are anonymous selfreport forms designed to ascertain participants posttreat-ment evaluation of IFP Fristad & Gavazzi, 1994. These forms were given to the parent and child in envelopes by the treatment ther-apist immediately after their final IFP therapy session.After completion, the parent and child placed the form in a sealed envelope and re-turned it to the treatment therapist to give to the principal investigator. Procedure All recruited families completed T1 baseline assessment batteries, and the obtained information was presented at an initial case review to determine study eligibility, as previously described. If eligible, participants were randomized, by pairs, into the immediate IFPplus treatment as usual condition IFP TAU, N 10 or a waitlist-control condition plus TAU WLC TAU,n 10. Statistical analy-ses revealed the IFP TAU and WLC TAU groups were similar on all baseline demographic variables i.e., childs gender, age, IQ, ethnicity, family structure! and clinical variables i.e.,

baseline MSI score, comorbid be-havior disorder, comorbid anxiety disorder, type of BPD. The IFP TAU group then received 16 50-min sessions, alternating between parent-only sessions and, after the requisite check-in, child-only sessions, as previously described. Followup assessments of both groups were conducted at T2 6 months after study entry!and T3 12 months!and at T4 18 months. Following the T3 assessment, the WLC TAU group received IFP. Therapists included two clinical psychology postdoctoral study coordinators and one clinical psychology doctoral candidate who also served as a parent advocate for the Child & Adolescent Bipolar Foundation. Results Impact on childrens mood. Children im-proved immediately following treatment, with gains continuing for 12 months post IFP see Figure 1, high scores more symptom severity. Power calculations Cohen, 1988 using a .05 and power .80 indicate that from baseline to 6 months, an effect size of .45 was detected, with 64 participants per cell needed to find significance in a larger sample. From baseline to 12 months, an effect size of .60 was detected, with 36 participants per cell needed to detect significance. Impact on family climate. Changes in EEAC total score were significantly better for IMM families, F 2, 8 3.16,p,.10, see Figure 2; high scores better family climate. Power calculations~Cohen, 1988 usinga .05, power .80, and assuming a twotailed alternative hypothesis indicate 37 participants per cell would be needed to find significance in a subsequent study. Impact on treatment utilization. Overall service utilization improved in the IMM families to a nonsignficant degree see Figure 3; high scores better treatment utilization,F 2, 10 2.28, p.15. Power calculations Cohen, 1988 usinga.05, power .80, and assuming a twotailed alternative hypothesis indicate 114 participants per cell would be needed to find significance in a subsequent study. Consumer evaluation.In addition to the seven study dropouts, two mothers and three children did not complete and return treatment evaluations following their final therapy ses-sion. Thus, only 11 parent and 10 child evaluations were available for review. Evaluations were positive, as seen in Table 2. Summary.Multiple positive outcomes of IFP are suggested by this pilot study. Notably, changes begin to occur by the 6-month Followup i.e., shortly after treatment ended but continue to accrue for the subsequent 6-month interval. Improvements in mood and family climate and possible improvements in treatment utilization all were most pronounced at the 12-month follow-up period. It may be that some changes resultant from psychoeducational approaches might take longer to become evident. We teach families how to become better consumers of mental health and school based care as part of the intervention, but achieving meaningful alterations in treat-ment plans is often a slow and arduous pro-cess, such that the clinical benefit garnered from such alterations is slow in coming. Expanded 24 session IFP As with our MFPG pilot study, following IFP pilot study completion, we conducted a review of our treatment program. First, we examined anonymous posttreatment qualitative and quantitative feedback from parents and children. Second, we reviewed supervision notes from each therapy session to identify problem areas in treatment provision. As with MFPG, this review led to an increase in the number of IFP sessions from 16 to 24, thereby matching the amount of therapist face time with the family for IFP and MFPG.i.e., two groups parents, children, 90 min each, eight sessions is equivalent to 24 60-min sessions. Our research group is currently conducting a pilot study on this extended 24-session IFP protocol. IFP-24 includes 20 set sessions and 4 in the bank sessions, to be used as needed

to reinforce learning or manage crises. Com-pared to the original IFP, there are five new content sessions and three additional in the bank sessions. New session content includes an additional session for the parent and child to review symptoms and diagnoses, expan-sion of the one session for parents to learn about options in mental health services and school services into two sessions, an addi-tional Healthy Habits session, a session for school professionals, and a session devoted to sibling issues. The study is nearly complete. Outcome data are still being collected, but preliminary findings suggest session format is acceptable to families Davidson &Fristad, in press. In their final session, parents and children are asked to write words of wisdom for subsequent treatment families. Parents sample words of wisdom include Take a break when you need it, parents need time for them-selves to regroup...Dont be embarrassed, its no ones fault...Focus on the good things about your child, whereas childrens words of wisdom include our motto, Its not your fault but its your challenge. Summary Data from studies of adults and adolescents with depression and BPD suggest the impor-tance of concomitant psychosocial interventions to improve outcome. Our research team has developed, refined, and tested various psy-chosocial interventions for mooddisordered children. We have completed a pilot study of agroup based intervention, MFPG, in 35 chil-dren with mood disorders, are testing MFPG in a larger randomized clinical trial of 165 children with mood disorders 115 of whom have BPD, have completed a pilot study of IFP in 20 children with BPD, and are completing a small pilot study of an expanded 24-session version of IFP. Cumulatively, these clinical trials suggest a combination of sup-port, psychoeducation, and skill-building are effective in increasing understanding of mood disorders, reducing mood symptom severity, enhancing family climate, and improving treat-ment utilization. In addition, parents and children find participating in psychoeducational interventions a positive experience. There are potential advantages and disad-vantages of both MFPG and IFP. MFPG is expected to increase social support, provide peer0adult feedback, in vivo practice and dis-cussions with peers0other parents who experience similar problems. Although MFPG offers the very unique advantage of social support from adult and child peers, it will probably not be feasible to offer except in larger clinic settings, thereby depriving a large number of children and families from accessing this specialized care. IFP, on the other hand, is more readily provided regardless of community size, location, or treatment facility available for care. IFP is expected to offer numerous pragmatic advantages, such as ease in sched-uling, the opportunity to individualize content to address specific needs of the child or fam-ily and, because not all families or treatment settings can utilize group treatment, increased transportability. Both MFPG and IFP are well received by parents and children. Of note, there are many unanswered ques-tions about potential mediating variables that may impact treatment outcome. Several of these are discussed in this article, including family concordance, childrens social skills, parent and child hopelessness, and family stress. All of these are targeted by psychoeducational intervention, and may contribute to greater mood stability in children who show improvements in these areas. In this paper, we have reported findings from pilot studies of MFPG and IFP. A largescale clinical trial of MFPG is nearing completion that should ad-dress questions of mediating and moderating variables for that treatment modality. A more rigorous evaluation of IFPs efficacy and

documentation of variables that mediate and moderate its impact on childrens mood severity is warranted.