CHICAGO—"Can we identify children who are at risk for developing a more serious disorder on the basis of subthreshhold symptoms, and is there anything we can do in terms of prevention to keep subsyndromal symptoms from escalating into a fully syndromal disorder?” These were the questions posed by David J. Miklowitz, PhD, at the 55th Annual Meeting of the American Academy of Child and Adolescent Psychiatry.

According to the NIMH-funded Course and Outcome of Bipolar Youth study, 25% of children with bipolar disorder not otherwise specified (NOS) convert to bipolar I or II disorder within about 18 months. Such children usually have shorter, subsyndromal episodes of mania, said Dr. Miklowitz, who is a Professor in the Depart ment of Psychology at the University of Colorado, Boulder.

Risk for bipolar disorder can be defined on the basis of symptoms alone. Because mood instability of early onset is associated with social and academic impairments, multiple comorbidities, sexual and/or physical abuse, divorce or other family disruptions, and other life events, a child’s environment plays as important a role as genetics in bipolar disorder. Although pharmacologic treatment may stabilize a child at risk for bipolar disorder, no single drug has proved effective in preventing or delaying the severity of the disorder once it develops. For this reason, said Dr. Miklowitz, “we really need indicated prevention strategies that can delay, or at least minimize, the severity of the condition once it has developed.”

FAMILY-FOCUSED THERAPY

One intervention strategy that has shown promise in adults with bipolar disorder is family-focused therapy (FFT). Consisting of psychoeducation about bipolar disorder, problem solving, and communication enhancement, FFT is a 21-session treatment program for adult patients and diagnosed adolescents and their families, conducted on an outpatient basis. A modified, 12-week version of FFT has been used for children and adolescents at risk for bipolar disorder, in which the family is educated about the disorder (ie, symptoms, early recognition of recurrence warning signs, importance of taking medication, family tree) and taught what to do if a child’s symptoms begin to escalate. As time progresses, treatment becomes skill oriented, centering around effective speaking and listening skills in an attempt to defuse the highly emotional interchanges that often occur in families of children with bipolar disorder.

In a two-year study by Dr. Miklowitz and colleagues, 58 adolescents (mean age, 14.5) who had been diagnosed with bipolar disorder that began with an acute episode were randomly assigned to either 21-session FFT plus medication or enhanced care (three sessions of family psychoeducation), with crisis intervention as needed. The majority of the teens were non-Hispanic white, and nearly half lived with both biological parents. Results of the study showed that adolescents in the FFT group recovered from their depression faster and stabilized four weeks sooner than those in the enhanced care group. The groups did not differ in time to recurrence of depression or mania, but adolescents in the FFT group spent fewer weeks in depressive episodes and had a more favorable trajectory of depression symptoms for two years. However, the results were not as striking for mania. “This is one of the reasons we thought of extending this treatment to kids with bipolar disorder. Many present with major depressive symptoms, and you have to do a lot of guesswork as to whether they’re going to develop mania in the future,” explained Dr. Miklowitz.

These findings led Dr. Miklowitz, in collaboration with Kiki Chang, MD, and his colleagues, to undertake an ongoing indicated prevention study of 50 children ages 9 to 17 with bipolar disorder NOS and symptoms of mania that have lasted at least two days, caused a change in functioning, and recurred four times during the child’s lifetime.

“We want to develop the treatment, show that it reduces symptoms, and then do a larger-scale, longer-term study to see if we can actually prevent conversions to bipolar I or II in these kids,” Dr. Miklowitz stated. Specifically, he said, study outcomes include trajectory of mood symptoms, amount of time stable, and ultimately, conversion to bipolar I or II.

Among the changes needed to adapt the study to an at-risk population were decreasing the number of sessions from 21 to 12, ensuring that the affected parent has been stabilized, encouraging regulation of the child’s mood, limiting emphasis on medication, simplified rather than highly technical handouts, and a more flexible session structure for younger children, such as walking outside or drawing during sessions.

“FFT may be an effective way to engage kids at risk for bipolar disorder,” Dr. Miklowitz concluded, adding that the essential components of treatment—building a strong family alliance with productive communication, psychoeducation, management tools such as mood charts, and removing barriers to treatment adherence—are “the kind of intervention[s] that could be done with any disorder to positive effect.”

—Alexa Arce

Suggested Reading
Miklowitz DJ, Axelson DA, Birmaher B, et al. Family-focused treat-ment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry. 2008;65(9):1053-1061.

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