Treatment Moderators of Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder

Abstract

Objective-Prior work has demonstrated the efficacy of child-and family-focused cognitivebehavioral therapy (CFF-CBT) versus enhanced treatment as usual (TAU; unstructured psychotherapy) for pediatric bipolar disorder (PBD). The current study builds on primary findings by examining baseline child, parent, and family characteristics as moderators of symptom response trajectories.Method-Sixty-nine youth ages 7-13 (M = 9.19, SD = 1.61) with DSM-IV-TR bipolar I, II, or not otherwise specified (NOS) were randomly assigned, with family members, to CFF-CBT or TAU. Both treatments consisted of 12 weekly sessions and 6 monthly booster sessions. Participants were assessed at baseline, 4, 8, and 12 weeks, and 6-month follow-up on mania and depression symptoms and overall psychiatric severity. Parents and youth also provided self-report data on baseline characteristics.Results-CFF-CBT demonstrated greater efficacy for youth depressive symptoms relative to TAU for parents with higher baseline depressive symptoms and lower income, and marginally for families with higher cohesion. In addition, youth with lower baseline depression and youth with higher self-esteem showed a poorer response to TAU versus CFF-CBT on mania symptom outcomes. Age, sex, baseline mania symptoms, comorbidity, and suicidality did not moderate treatment response. Disclosure: Dr. Weinstein has received honoraria from the University of Lund (academic talk) and American Foundation for Suicide Prevention (community talk). Dr. Henry has received funding from the National Institute of Justice, National Institute of Drug Abuse, NIMH, Centers for Disease Control and Prevention, and the McCormick Foundation. He has received honoraria and consultancies from Rush University, the Center for Alaska Native Health Research, and the University of Virginia Curry School of Education. He is also affiliated with the University of Alaska, Center for Alaska Native Health Research, where he holds a President's Professor appointment. Dr. West has received honoraria from the National Institutes of Health (grant review), Northwestern University (Grand Rounds), and University of Lund (academic talk). Ms. Katz and Ms. Peters report no biomedical financial interests or potential conflicts of interest.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access

Parenting Stress Among Caregivers of Children With Bipolar Spectrum Disorders

“…Such parent and family variables have also been found to predict and moderate treatment effects. While more impaired children and families tend to benefit most from EBTs for BPSD (MacPherson et al, 2014; Miklowitz et al, 2009; Weinstein et al, 2015) and disruptive behavior (Gardner, Hutchings, Bywater, & Whitaker, 2010), caregiver stress is generally predictive of worse treatment outcomes for anxiety (Compton et al, 2014; Crawford & Manassis, 2001), though treatments with active parental involvement are highly effective for anxious children (Manassis et al, 2014). Thus, families of children with anxiety, disruptive behavior, or especially BPSD, experience considerable stress and may require more structured and intensive interventions with high levels of parental involvement to experience benefit.…”

“…In addition, while poor child functioning has been implicated as a treatment moderator for pediatric BPSD (MacPherson, Algorta, Mendenhall, Fields, & Fristad, 2014), parent and family variables also moderate treatment outcomes. Specifically, moderators include elevated parent depression (Weinstein, Henry, Katz, Peters, & West, 2015), low income (Weinstein et al, 2015), elevated negative expressed emotion (Miklowitz et al, 2009), and increased conflict (Sullivan et al, 2012), with more impaired children and families generally benefitting most from EBTs for BPSD. Finally, parent and family constructs can mediate improvements in child mood symptoms and functioning in response to EBTs.…”

Mediators in the randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy for pediatric bipolar disorder

“…Moderator analyses indicated that CFF-CBT was most impactful for parents with severe depression and low income, and families with high cohesion (Weinstein, Henry, Katz, Peters, & West, 2015). In addition, children with milder depression and greater self-confidence fared more poorly in TAU.…”

Intervening early in children with bipolar disorder: is there a pot at the end of the Rainbow?

“…Rainbow integrates individual CBT with family psychoeducation and mindfulness skills sessions. In a second article, using the same cohort as the West et al study, Weinstein et al 7 examined baseline child, parent and family variables as potential moderators of response to CFF-CBT or a treatment-as-usual (TAU) comparison group.

Elements of the RAINBOW Programme6 7

R= R outines (developing consistent daily habits)

A= A ffect Regulation

I= I can do it!

…”

“…For example, Beardslee et al 8 found that adolescents with a history of depression who participated in a group cognitive-behavioral therapy prevention programme had fewer onsets of depression over 33 months if mothers were not depressed at intake; those whose mothers had depression at baseline responded equally to the CBT prevention programme and the usual care comparator. In the West et al 6 paediatric bipolar trial, however, the interaction between parental depression, treatment and time is best understood as variability in the within-group symptom trajectories 7. Children responded similarly to CFF-CBT (ie, showed comparable levels of improvement in depression scores) independently of their parents’ levels of depression.…”