Preliminary results from an exploratory investigation of a new, developmentally
sensitive intervention for pediatric bipolar disorder (BD) show promise, say
the authors of the study. "This empirically-based treatment was effective
in reducing symptoms for pediatric bipolar disordered children," says
Julie Carbray, DNSc, administrative director of Mood Disorders at the University
of Illinois, Chicago, where the study was conducted. "Not only did it
reduce symptoms, but we also took a look at how well it helped parents adhere
to treatment and how satisfied they were with the program. It did very well
with both of those things."
Thirty-four children and adolescents were enrolled in an open
trial of child- and family-focused cognitive-behavioral therapy (CFF-CBT),
a method that integrates principles of family-focused therapy (FFT) with those
of cognitive behavioral therapy (CBT) and is used along with medication. The
acronym RAINBOW was coined to give families and children an easy framework
in which to think about the treatment protocol. The researchers say CFF-CBT
is an adaptation of the family-focused treatment model authored by David J.
Miklowitz and Michael G. Goldstein in their book, "Bipolar Disorder: A Family-Focused Treatment Approach".
That model emphasized a "psychotherapeutic attitude" in which
the experience, stories, and special life circumstances of the family members
are addressed. The developers of CFF-CBT believe the integrated model is well
suited to address the unique problems of BD, as it grounds treatment in a biological
theory of excessive reactivity and targets environmental stressors associated
with BD. CFF-CBT also incorporates psycho-education, support and therapy for
parents and affected youth and involves working with siblings and the school
system. In addition to looking for reduction in symptom severity and improvement
in overall functioning, the study evaluated adherence to the treatment protocol
by the therapist, compliance with attending psychotherapy sessions and parent
satisfaction. Measures used were the severity scales of the Clinical Global
Impression Scales for Bipolar Disorder (CGI-BP) and the Children’s Global
Assessment Scale (CGAS).
Study parameters
The 34 participants, 24 boys and 10 girls ranging in age from 5 to 17 years
old, were drawn from a specialty clinic at the University of Illinois at
Chicago. All were stabilized on medication, and all were diagnosed with bipolar
disorder using the Washington University in St. Louis Schedule for Affective
Disorders and Schizophrenia for School-Age Children (WASH-U-KSADS). In addition
to the primary diagnosis of bipolar disorder, inclusion criteria also required: (1) a
score on the Young Mania Rating Scale (YMRS) of more than 15, but less than
20 to ensure that participants would be receptive to psychotherapeutic strategies; (2) a
standard score of more than 70 on the Wide Range Achievement Test (WRAT)
to indicate basic academic competencies; (3) living arrangements
with a parent or significant adult guardian; and (4) on
medications supervised by a physician. Twenty-eight of the 34 had a primary
diagnosis of bipolar disorder type 1, three were diagnosed with bipolar disorder
type 2, and three were diagnosed with bipolar disorder not otherwise specified.
The most prevalent comorbid conditions were attention deficit/hyperactivity
disorder (ADHD) (73.5%), oppositional defiant disorder (35%), and learning
disorders (32%). A board-certified child and adolescent psychiatrist and
an advanced
practice nurse in child psychiatry conducted the interviews. A single therapist
consistently applied the CFF-CBT protocol over 12 hour-long sessions with parents
and children actively engaged. The CGI-BP was completed by the therapist at
the beginning of treatment, at the end of each session, and at the end of treatment.
Severity items cover a variety of symptom dimensions such as mania, depression,
ADHD, psychosis, aggression, and sleep disturbances. The CGAS was completed
by the therapist at the beginning and end of treatment. At the end of treatment,
parents or guardians also completed a satisfaction survey that used a 5-point
Likert scale with anchors 1 = very dissatisfied to 5 = very satisfied.
Symptom reduction
Carbray says that while the research team felt fairly confident about the construction
of the treatment program and how effective it might be, it actually did better
than they expected. To determine changes in the CGIBP symptom severity ratings
from the beginning to the end of treatment in both conditions, the researchers
conducted a series of paired comparison t tests. They found significant reductions
in symptoms. "Some of the symptoms that were reduced by this program
were surprising," says Carbray. "We wouldn’t have thought
that kids would have a better quality of sleep as a result of educating parents
about how important sleep is. ADHD symptoms also showed some improvement
as well, and those weren’t things we were really looking for, so those
were nice surprises." On CGI-BP Overall Improvement (CGI-I) scores,
100% (34/34) of the sample scored 2 or less after treatment compared to none
before treatment. Changes in CGAS scores from the initiation to the conclusion
of treatment indicate that participants were functioning significantly better
at the end of treatment compared to their pretreatment levels. High levels
of treatment integrity, adherence, and satisfaction were achieved, as well.
Clinical implications
"We have something here that is clinic friendly and that clinicians can
do that shows efficacy with our bipolar families," says Carbray. "Typically,
when you devise a treatment protocol its research based, and you can do it
really well in a lab, but when you bring it to clinics it may not work because
the conditions change. Our goal in pulling this program together was to have
something that would be fairly easy for clinicians to use to help families
learn together." For clinicians providing psychosocial treatment to patients
with early-onset bipolar disorder, the availability of a practical and manualized
treatment protocol is important. The RAINBOW metaphor, designed for ease of
use for clinicians and attractiveness to families, is introduced in the first
session as an advanced organizer and is used throughout treatment to provide
a meaningful and cohesive framework to the treatment process. "We tried
to come up with an acronym so that parents would be able to come in and say, ‘We’d
like to talk about the R today,’ or ‘We’re really having
trouble with that whole A zone.’ It gives them a way to measure their
successes with treatment," says Carbray.
The RAINBOW program scored high marks for treatment integrity, attendance
at scheduled appointments, and consumer satisfaction, says Carbray. One of
the unique advantages of CFF-CBT is its flexibility in the timing of family
treatment to address individual family needs. Another distinctive feature of
CFF-CBT is its inclusion of siblings in treatment to learn cognitive-behavioral
strategies for improving their own coping skills. In addition, no patients
were excluded due to comorbid conditions. The results suggest the usefulness
of CFF-CBT for a wide range of ages, say the researchers, although future studies
may be designed to focus on 8- to 12-year-olds and 13- to 18-year olds separately,
as a larger sample or age-specific techniques may have specific effects on
clinical efficacy. "Our goal is to take a look at treatment as usual
versus our RAINBOW treatment," says Carbray. "We just completed
a study using the RAINBOW treatment in a group format. We are looking at many
different ways to be able to take this treatment one step further with a larger
group and see how it looks."
The RAINBOW Program
The CFF-CBT model uses the acronym RAINBOW, and the treatment model is introduced
to parents and children as the RAINBOW program: Routine: A predictable, simplified routine will reduce excessive
reactions and tense negotiations in responses to changes in schedule. For instance,
a good sleep schedule is essential for children with BD, as being tired makes
them more susceptible to intense moods. Affect Regulation: Apart from the medication, consistent self-monitoring
of moods is encouraged. Parents are encouraged to serve as positive role models
for their children with BD. For example, when their child is reacting excessively
to a situation, parents are instructed to maintain a neutral expression while
expressing calming yet appropriate words. I Can Do It!: Generating a list of positive self-statements
will help the child develop a more positive view of himself or herself and
increase motivation to engage in effective problem-solving. Encouraging parents
to mention the child’s positive qualities can help the child with BD
comprehend the genuineness of the parent’s attempts to offer positive
feedback. No Negative Thoughts & Live in the "Now": After
a difficult episode, both children and parents need the opportunity to debrief
and express sad and difficult feelings to reduce resentment. This psychoeducational
component teaches children and families how to differentiate helpful from unhelpful
thoughts and to reframe the unhelpful thoughts into helpful ones that will
lead them to discover more effective problem-solving strategies. Be a Good Friend and Balanced Lifestyle for Parents: Peer
relations are central to self-esteem and represent a major developmental context
for children and adolescents. Supportive friendships are associated with decreased
symptoms of depression, anxiety and loneliness. Yet children with BD often
experience significant difficulties relating to peers. They can be hypersensitive
to the reactions of others and demonstrate intense reactions of jealousy and
bitterness in response to perceived or actual slights by their peers. Thus,
a major goal of RAINBOW is to help children establish and maintain friendships.
Children are taught the skills necessary to be a good friend and are provided
opportunities within the therapy sessions to practice the skills. Parents are
also encouraged to seek opportunities for the child to practice newly developed
skills and develop friendships (e.g., sleepovers, play dates, and supervised
group activities). Oh, How Can We Solve the Problem?: When the child is calm,
skills need to be actively taught and practiced. Parents are encouraged to
view children as partners in the problem-solving process and to explain the
pros and cons of potential solutions in an empathic way. Through pep talks
and roleplaying, children can learn appropriate ways to handle an upcoming
situation. Ways to Get Support: Feeling accepted, supported, and loved
helps individuals feel less threatened and isolated. Perceived support can
be different from viable practical support for children. During therapy, the
therapist and child draw a support tree that includes the names of people who
can help him or her through difficult situations. They then talk about when,
how, and where the child can go for support and what are appropriate expectations
of others.
- Pavuluri, M N, P A Graczyk, and D B Brown; RAINBOW: Two programs combined
may be better than one for pediatric BD; Brown University Child & Adolescent
Behavioral Letter; Jul2004, Vol. 20 Issue 7, p1
Personal
Reflection Exercise #10
The preceding section contained information
about the RAINBOW method for treating pediatric bipolar disorder. Write
three case study examples regarding how you might use the content of this section
in your practice.
Reviewed 2023
Update
Self-regulation in youth with bipolar disorder
- Khafif, T. C., Kleinman, A., Rocca, C. C. A., Belizário, G. O., Nader, E., Caetano, S. C., & Lafer, B. (2023). Self-regulation in youth with bipolar disorder. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 45(1), 20–27. https://doi.org/10.47626/1516-4446-2022-2668
Peer-Reviewed Journal Article References:
Fortney, J. C., Pyne, J. M., Ward-Jones, S., Bennett, I. M., Diehl, J., Farris, K., Cerimele, J. M., & Curran, G. M. (2018). Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics. Families, Systems, & Health, 36(3), 267–280.
Gellersen, H. M., & Kedzior, K. K. (2018). An update of a meta-analysis on the clinical outcomes of deep transcranial magnetic stimulation (DTMS) in major depressive disorder (MDD). Zeitschrift für Psychologie, 226(1), 30–44.
Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336.
QUESTION
24 According to Pavuluri, what are two distinctive features of the RAINBOW treatment
model? Record the letter of the correct answer
the Test.