Psychoeducational Psychotherapy (PEP) for Children With Bipolar Disorder: Two Case Studies

Abstract

Treatments for children with bipolar disorder are limited. Psychosocial interventions are considered essential to improve overall functioning, but evidence-based treatments are scarce. We present results from 2 children treated with an expanded version of individual family psychoeducational psychotherapy (PEP; Fristad, 2006). Children’s Global Assessment Scale scores and 3 of 4 mood scales improved after treatment. Parents and children reported improved family interactions. Parental attitudes toward treatment improved. Consumer evaluations indicated parents and children found the intervention length to be appropriate; benefits were noted in child and family functioning and interfacing with the child’s school. Additional evaluation of PEP appears warranted.

INTRODUCTION

Bipolar disorder (BPD) in children is a chronic, cyclical, relapsing, severe, and highly comorbid condition (Geller, Tillman, Bolhofner, & Zimerman, 2008; Lewinsohn, Seeley, & Klein, 2003) associated with significant psychosocial impairment at home, in school, and with peers; a high degree of mental health utilization; multiple hospitalizations; and suicidality (Lewinsohn et al., 2003). Although medication is a critical treatment component, psychosocial interventions play a pivotal role in promoting medication compliance, teaching relapse prevention skills, and improving psychosocial functioning (American Academy of Child and Adolescent Psychiatry, 2007; Kowatch et al., 2005). BPD may be exacerbated by environmental factors such as family, teacher, and peer conflict; academic stress; and sleep-wake cycle disruption; therefore, improving families’ abilities to manage these potential stressors is critical (Lofthouse & Fristad, 2004).

Adding psychotherapy to pharmacotherapy is recommended as soon as the child’s mood is stable enough to learn new skills (Kowatch et al., 2005). All the treatments developed for youth with mood disorders include a psychoeducational component (Young & Fristad, 2007). Fristad and colleagues have developed and examined family-based psychoeducational psychotherapy (PEP) interventions for 8- to 12-year-old children with mood disorders (Fristad, 2006). PEP is designed to teach parents and children about mood and cooccurring disorders; pharmacological, mental health, and school-community focused interventions; and coping skills. It aims to decrease blame and empower families to become active and informed consumers by promoting individual and family strengths. PEP is considered adjunctive, and families are encouraged to continue any medication management, school-based services, or other helpful interventions they are receiving. Treatment has been provided in multifamily (MF-PEP) and individual-family (PEP) formats.

MF-PEP and PEP have been tested in multiple clinical trials, with efficacy demonstrated across various outcomes including decreased mood symptom severity, increased knowledge of mood disorders, increased positive family interactions, increased efficacy in seeking treatment, improved coping skills, improved attitude toward child/treatment in parents, increased social support from parents, and parent and child satisfaction with treatment (Fristad, 2006; Fristad, Goldberg-Arnold, & Gavazzi, 2003; Fristad, Verducci, Walters, & Young, 2009). The original PEP format included 16 sessions, 15 scripted (i.e., with specified content to cover within each session) and one “in-the-bank” session to be used at the family’s request to either delve deeper into a particular treatment component or for crisis management. Although posttreatment feedback from parents in the original PEP trial was positive, families and the clinicians treating them desired an expanded focus and intensity of treatment (Fristad, 2006). Additionally, the adult BPD treatment literature provides support for targeting stabilization of sleep and social routines (Frank, Gonzalez, & Fagiolini, 2006). Weight gain associated with medications commonly used to treat BPD indicated a need to incorporate exercise and healthy eating into treatment plans (Kowatch et al., 2005). Thus, PEP was expanded from 16 to 24 sessions. One session was added in which siblings participate to assist them to better understand and cope with BPD; the session on mental health and school-based services was divided into two separate sessions to focus more attention on each; a session was added to which school professionals were invited to participate either through face-to-face or conference call attendance; and two sessions were added to attend in greater detail to children’s health behaviors (sleep hygiene, exercise, diet), these topics previously had been incorporated into other existing sessions. Also, the number of in-the-bank sessions families could request was increased from one to four. In both the original and expanded versions of PEP, children and parents are encouraged to write down questions or concerns that arise between sessions to bring in to subsequent sessions. They are also provided telephone contact information for the therapist in case of emergencies or if they have urgent questions between sessions. This article describes implementation of an expanded PEP, with 20 scripted and 4 in-the-bank sessions, for two children and their families.

DESCRIPTION OF PEP

In PEP, child sessions alternate with parent-only sessions. Siblings and school professionals are each invited to a session; the latter join either via conference call or in person, based on their preference. Child sessions begin and end with parents in the room, reviewing the past week’s project at the beginning of the session and summarizing session content and the pending weekly project at the end of the session. After parents leave each child session, the child describes his or her current feelings via a feelings chart and thermometer, reviews previous treatment content, and then proceeds on to the Lesson of the Day and an explanation of the next week’s project. Before parents rejoin, the child practices deep breathing, one of the calming techniques used in treatment.

Session content and related projects are summarized in Table 1. The first four sessions are more psychoeducational in orientation. Sessions focus on symptoms, diagnoses, how to differentiate symptoms from the child’s personality, and medications. The remaining 16 scripted sessions are more skill building in orientation. Children and parents receive workbooks to use throughout treatment and weekly homework assignments (called “projects”) are used to practice skills. Children earn points for session participation and homework completion, which are traded for prizes in the last session. Treatment components are described in detail elsewhere (Fristad, Goldberg Arnold, & Leffler, in press).

TABLE 1.

PEP Session Content

Session	Attends	Content	Project
1	C	Overview, Goals, Symptoms, and Diagnoses	Fix-It List
2	P	Mood Facts, Symptoms, and Diagnoses	Mood Log
3	C	Differentiate Self vs. Symptoms Medications—monitoring and managing side effects	Naming the Enemy
4	P	Medications—monitoring and managing side effects	My Child’s Medications
5	C	Healthy Habits (diet, sleep, exercise)	Healthy Habits Chart
6	P	Mental Health Services	My Child’s Treatment Team
7	C	Emotion Regulation Skills, Building a “Tool Kit”	Taking Care of Mad, Bad, Sad Feelings
8	P	Negative Family Cycles, basics of cognitive-behavioral therapy (Thinking-Feeling-Doing)	Thinking-Feeling-Doing
9	C	Thinking-Feeling-Doing	Thinking-Feeling-Doing
10	P	Coping and Problem Solving Skills	Family Problem Solving
11	C	Problem Solving	Problem Solving
12	P	School Services	My Child’s School Team
13	C	Review Healthy Habits	Healthy Habits Chart
14	SP	School Planning	None
15	C	Nonverbal Communication	Paying Attention to Feelings
16	P	Communication	Out with the Old, In with the New
17	C	Verbal Communication	Let’s Talk
18	P	Symptom Management	Let’s Talk
19	Sibling	Sibling Session	None
20	P&C	Wrap up, Graduation	None

Note. P = parent; C = child; SP = school professional. Four additional “in-the-bank” sessions can occur at any time during treatment.

REASON FOR REFERRAL/BACKGROUND INFORMATION

On approval to conduct this study from the local institutional review board (IRB), the postdoctoral study coordinator/therapist initiated contact with families from an existing waiting list of families who had initiated contact with the research program, requesting to remain on a waiting list for future treatment studies. Due to a lengthy delay in receiving IRB approval, the therapist was only able to enroll the first two eligible families seeking treatment as his postdoctoral training was nearly complete. They were administered a brief phone screening interview to determine potential study eligibility (the family had to be willing to participate in the assessment and treatment protocol, the child had to be between the ages of 8 and 12 and have a high probability of being diagnosed with BPD if enrolled). Parents provided written informed consent and children provided assent to participate in a clinical trial prior to study entry. Treatment was provided at no charge and parking passes were provided at each assessment and treatment session. Names, ages, and other identifying information have been altered slightly to protect the families’ identity. Children included an 11-year-old White girl (“Jane”) and a 10-year-old White boy (“John”). Each was living with their biological parents and a sibling. Their clinical histories are summarized here.

Jane

Jane presented with significant mood lability and was excessively guarded. She appeared unkempt, with uncombed, mangled hair, a soiled jacket, dirty pants, and severely chapped hands. Her mother reported the latter was due to Jane’s excessive washing of and picking on her skin. Jane’s parents had experienced significant marital conflict and a brief divorce, followed by remarriage. During this time, Jane reportedly changed from a “vibrant and popular child” to one who could not keep friends. Once, Jane had to be picked up from school as she was lying in a fetal position crying inconsolably. Recently, Jane had been verbally and physically aggressive toward her parents, displaying rapid, tangential, and incoherent speech; exhibiting disruptive behaviors at school; engaging in socially inappropriate interactions; and participating in risky behaviors that had required medical attention. On one occasion, Jane became so upset her mother was leaving home on an errand that she ran barefooted after her mother’s car. After being let into the car, Jane attempted to jump out the window. Once back home, she ran from her family and tried to jump out of a second-story loft yelling, “I can fly, I’m going to jump!” When family members attempted to calm her, she accused them of trying to kill her and hit them with a bar. She then fled to her bedroom and moved a large dresser in front of the door. Jane’s parents were unable to enter her bedroom or persuade her to come out. Out of desperation, they called the police and emergency medical technician (EMT), who forcibly removed her door and convinced Jane to take her medications to prevent hospitalization. Jane’s mother reported Jane’s mood episodes fluctuated throughout the day, with sad moods “on and off” all day, accompanied by irritability, restlessness, excessive fatigue, and negative views of self. At other times during the day, Jane experienced an elevated activity level, rapid thoughts and speech, overestimation of her abilities, hypersexuality, and dangerous behaviors. Duration could vary from minutes to hours, frequency ranged from a few times a day to several times a week. Jane’s mood disturbance had been present for 2 years without full remission, despite short durations of more stable functioning. Family history included mother’s past anorexia, bulimia, panic disorder, and posttraumatic stress disorder and father’s current BPD and symptoms of obsessive-compulsive disorder.

Jane had been treated for mood dysregulation for the past year. A behavior analyst worked with Jane at school; Jane refused to engage in outpatient therapy. Jane’s mother received outpatient parent guidance. Regarding medication, Jane received a 3-month trial of sertraline at age 8. This resulted in akathesia, elevated moods, and excessively dangerous behaviors. Between ages 9 and 10, Jane had trials of divalproex sodium and clonidine, neither of which produced significant improvement. Jane then started quetiapine, from which she was being tapered due to lack of efficacy at the time of her evaluation. For the past year, Jane had been prescribed fluvoxamine and clonazepam to manage compulsive behavior and to decrease agitation.

John

John presented as restless with excessively distorted thoughts and limited insight. At times during the interview, John stared blankly and was unresponsive to verbal requests. At other times, he would become very animated and overly active. On several occasions, John began to hit and choke himself but could be redirected. John’s mother reported a long-standing history of engaging in dangerous behaviors, including trying to eat a light bulb and hitting and biting himself and others. These behaviors intensified on preschool entry. John’s mother reported his mood symptoms could “be stable or flare up.” For example, John would have “good and bad times” throughout his preschool day, and some weeks were worse than others. Additionally, in the last few months of preschool, staff required his mother remain on-site to assist in managing his disruptive behaviors. As John got older, his mood and accompanying symptoms occasionally remained relatively stable for 4 to 5 months at a time then would flare up for 4 to 5 months. John’s mother attributed this to his medications working for a little while then being less effective, seemingly due to physical development. For 4 years, John had not gone for more than 6 months without needing a medication readjustment. During mood episodes, John frequently displayed severe behavioral and emotional outbursts, thought impairment, rapid speech, and sexually inappropriate behaviors. At these times, John attempted to touch his mother’s genital and breast areas, commented repeatedly on her private anatomy, and joked about breast-feeding. In the third grade, John began receiving educational services through a school designed for children with behavioral and emotional disorders. There is a family history of paternal depression and manic symptoms.

John’s outpatient treatment began at age 2, when he was prescribed divalproex sodium. At age 4, risperidone was added, atomoxetine at age 6, and oxcarbazepine at age 10. At intake, John was taking all four of these medications. Other trials included methylphenidate, age 2; methylphenidate, amphetamine/dextroamphetamine, clonidine, lithium, and aripiprazole, age 8; and quetiapine and escitalopram, age 9. Since starting medications, John gained an excessive amount of weight. At intake, he weighed 25 pounds more than his 11-year-old brother. John had also been diagnosed with and treated for hypothyroidism. He had been evaluated for a seizure disorder due to staring episodes, but results were not consistent with seizure activity.

ASSESSMENT AND DIAGNOSIS

Guidelines for evidence-based assessment of childhood BPD were considered in developing an assessment battery to establish diagnosis and monitor progress. Important components include a clinical interview with the child and one or more parents, detailed assessment of mood symptom severity and history of symptom cycling, and a detailed family history (Danner & Fristad, 2009). Psychoeducational treatments have been shown to improve family expressed emotion and attitudes toward treatment, which mediate improved treatment utilization and outcome (Mendenhall et al., 2009); measures were administered to track possible changes in these constructs as well. Measures are described in greater detail elsewhere (Fristad et al., 2009) and summarized here. All were administered pretreatment and posttreatment, unless otherwise indicated.

Measures

The Children’s Interview for Psychiatric Syndromes-Child (ChIPS) and Parent (P-ChIPS) Forms are structured psychiatric interviews designed to assess psychopathology according to Diagnostic and Statistical Manual of Mental Disorders fourth edition criteria with parents of children and adolescents (Rooney, Fristad, Weller, & Weller, 1999). ChIPS and P-ChIPS were administered at baseline to document lifetime and current presence/absence of psychiatric symptoms and syndromes. The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Mania Rating Scale (K-MRS; Axelson et al., 2003) and Depression Rating Scale (K-DRS; Ambrosini, Metz, Prabucki, & Lee, 1989) are mood severity rating scales. They were administered to determine mood severity in the worst (lifetime or since last interview) and current (past 2 weeks) time periods. The K-MRS rates manic symptoms on a 6-point scale: 1 (none), 2 (slight), 3 (mild), 4 (moderate), 5 (severe), 6 (extreme), with the exception of distractibility, which is rated on a 5-point scale. A cut-point of 12 on the 13-item K-MRS differentiates clinically significant manic symptoms with a sensitivity of 87% and specificity of 81% (Axelson et al., 2003). The K-DRS rates depressive symptoms on a 6-point scale, with ratings of 1 and 2 suggesting no or slight impairment. Ratings of 3, 4, 5, and 6 reflect mild, moderate, severe, and extreme symptoms, respectively. Two items are scored on a 7-point scale with 7 reflecting very extreme symptoms. The K-DRS has good test–retest reliability (r = .81) and internal consistency (Cronbach’s α = .72; Chambers et al., 1985). As a score of 3 or higher on K-MRS and K-DRS items suggests mild to extremely severe symptom presentation, these scores were considered to meet the diagnostic threshold.

The Children’s Global Assessment Scale (C-GAS; Shaffer et al., 1983) is a clinical rating scale to document children’s overall functional capacity. C-GAS scores range from 1 to 100 and represent levels of functional impairment with scores of less than 71 indicating significant impairment (Shaffer et al., 1983). Worst and current C-GAS scores were determined by two experienced clinicians in a consensus process after reviewing all assessment data.

The Expressed Emotion Adjective Checklist (EEAC; Friedmann & Goldstein, 1993) is a 40-item parent-report questionnaire of positive and negative emotions expressed by the parent and child toward each other. The Treatment Beliefs Questionnaire-Parent and Child Forms (TBQ-P and TBQ-C; Davidson & Fristad, 2006) are 36- and 17-item, respectively, self-report instruments to assess beliefs about treatments (pharmacologic and psychosocial). The Therapy Evaluation Parent and Child Forms are 15- and 13-item anonymous parent and child self-report forms, respectively, designed to ascertain participants’ posttreatment evaluation of PEP.

Baseline Assessment

Jane refused to complete the ChIPS; she met P-ChIPS diagnostic criteria for attention-deficit hyperactivity disorder (ADHD)-combined type, oppositional defiant disorder (ODD), separation anxiety disorder (SAD), generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), major depressive disorder (MDD), and mania. She had a history of specific phobia of elevators. John met ChIPS and/or P-ChIPS diagnostic criteria for ADHD (parent—combined type; child—inattentive type); ODD; specific phobia (parent—dark; child—heights), SAD, mania (P-ChIPS only), and dysthymic disorder.

Severe lifetime mood symptoms were reported for both Jane and John on the K-DRS and K-MRS. Currently, Jane was experiencing the following at a moderate or greater level of severity: dysphoric mood, irritability, psychomotor agitation, increased appetite, strong craving for sweets, weight gain, rejection sensitivity, irritability, motor hyperactivity, derailment, and mood lability. John was experiencing several areas of mild disturbance, but currently had no symptoms at the moderate or higher level. Mild symptoms included irritability, negative self-image, elevated mood, uninhibited people seeking, and hypersexuality.

Mood Diagnoses

Jane received a baseline mood diagnosis of BPD, most recent episode was mixed. John’s baseline mood diagnosis was BPD, most recent episode was hypomanic. These diagnoses were consistent with the diagnoses the children had received in the community.

TREATMENT PLANNING AND COURSE

Jane and John’s symptoms were quite disruptive of family life; thus, the family focus of PEP was important to outcome. Both Jane and John had highly impairing mood symptoms as well as comorbid diagnoses. Symptom profile information was used to tailor content within therapy sessions. Following the standard PEP outline was deemed appropriate in Jane and John’s treatment; however, the treatment manual does espouse the concept of “flexibility within fidelity” (Kendall & Beidas, 2007), such that sessions can be delivered in varying order if considered more appropriate in working with specific families (e.g., if a child’s sleep schedule is significantly irregular and contributing to mood instability, focusing on Healthy Habits early in treatment followed by an in-the-bank session to further monitor sleep might be preferred).

For each case discussed, we review all the child sessions, followed by the parent, sibling, and school professional sessions (although these alternate, as outlined in Table 1).

Jane

Initially, Jane was reserved and clearly stated she did not intend to participate in therapy. Despite her protests, Jane warmed up to the therapist after completing her baseline assessment. In her first session, Jane actively participated in learning about her symptoms and the PEP motto (“It’s not my fault but it’s my challenge”); however, she struggled with connecting this knowledge to her everyday life. In her second session, Jane easily identified the symptoms she regularly experienced but had difficulty identifying her positive traits on the Symptom-Self exercise. Her therapist was able to make suggestions based on information he had gleaned from her assessment; with these prompts, Jane was able to verbalize a few positive traits. She was encouraged to use these as a starting point with her parents when they worked on the activity at home. In session three, Jane focused on diet for her first Healthy Habits target. She was preoccupied with calorie counts and food intake. Jane’s mother reported this might reflect her own history of weight and dietary difficulties. Although Jane rated diet as the primary healthy habit to improve, she worked on diet, exercise, and sleep between sessions. At session four when she reviewed her Healthy Habits project, Jane described having made minimal progress regulating her calorie intake and increasing exercise, but she had developed a successful sleep routine. During that session, Jane eagerly identified a variety of potential coping techniques while constructing her Tool Kit but could not imagine actually applying them. By session five, Jane’s affect had improved and the skin on her hands was no longer chapped. While reporting on the previous week’s project, she was pleased to describe her success in a social interaction that had benefitted from using her Tool Kit. In this session, Jane required significant coaching to share her thoughts, feelings, and behaviors in the Thinking-Feeling-Doing exercise; with practice over the course of the session she became more adept at this.

During session six, Jane had difficult connecting the steps of problem solving. The Stop-Think-Plan-Do-Check exercise was used to help Jane problem solve how to manage her intense feelings when her mother would leave the house to run errands. Jane was unable to brainstorm any possible solutions, but when her mother joined the end of the session, she made several suggestions for Jane to try. During her seventh session, Jane reported working on Healthy Habits but stated she did not want to apply any other treatment skills outside of therapy. Despite this, at session eight Jane’s mother’s reported Jane was evidencing some improvement. In sessions eight and nine, Jane was able to accurately identify and apply verbal and nonverbal communication strategies. Jane appeared to have regressed at her final session. When asked to evaluate her progress, Jane stated she would recognize progress when her moods were different.

At the end of every session, Jane agreed to complete projects, but she only successfully completed three of nine assigned. With nearly every exercise, she said she would not benefit, yet there was some later evidence of improvement. Although Jane did not maximize her potential benefit from PEP, her ability to manage symptoms improved with treatment. Although Jane’s level of engagement in therapy was not ideal, it surpassed her previous refusal to participate in therapy whatsoever and her initial threat not to participate in this treatment.

When Jane’s parents presented for treatment, they conceptualized Jane’s problems very differently. Jane’s father believed her problems were all learned behaviors supported through inconsistent limits and her mother’s acceptance of Jane’s noncompliant and disruptive behaviors. Her mother viewed Jane’s difficulties as related to her mood dysregulation, and in an attempt to avoid agitating her, often tolerated inappropriate behaviors. This parental conflict is not uncommon when working with mood-disordered children; the therapist was able to address this conflict in several treatment sessions. In particular, parent session four addresses negative family cycles as well as “can’t” and “won’t” behavior, two critical topics for Jane’s parents.

Jane’s father attended only one scheduled parent session and one booster session due to work demands; however, Jane’s mother attended every parent session and reported reviewing session content via the treatment workbook with her husband between sessions. Jane’s parents opted to use an in-the-bank session to focus on triggers for Jane’s least desirable behaviors and on each parent’s feelings associated with disciplining or allowing specific behaviors. The therapist’s time constraints precluded utilizing any additional in-the-bank sessions.

Jane’s parents participated actively in treatment and successfully completed all weekly projects. They reported increased awareness of the struggles Jane faced due to her illness. This was most noted in her father’s better understanding of her illness, resulting in his reduced emphasis on Jane’s noncompliance and his wife’s leniency in her expectations. Jane’s father developed alternative reactions to Jane’s behaviors and a better understanding of her abilities to comply with requests. Jane’s mother made minimal gains in identifying when to respond to a “won’t” versus a “can’t” behavior. Jane’s parents continued to struggle with consistent agreement about expectations and responses but agreed to continue outpatient therapy to address these concerns while Jane continued to address coping strategies.

Jane’s younger brother attended the sibling session. He met one-onone with the therapist, during which time he vented his frustration over his sister’s difficulties, as it disrupted the home and diminished the time he got to spend with his parents, but also expressed sorrow over her challenges. He developed strategies to remind Jane about using her coping tools and to let his parents know about his feelings. Over the course of treatment, Jane’s mother reported her son appeared increasingly willing to be supportive of Jane and became more articulate in discussing his own feelings.

Jane’s behavior analyst attended the school professional session. Although already quite knowledgeable about Jane’s difficulties, he was open to learning new techniques to assist in regulating Jane’s mood. These included increasing the consistency and stability of her classroom environment; identifying a person she could confide in when distressed; developing a plan to call her mother when she began getting agitated to ward off an escalation (this strategy had been successfully implemented at home—Jane could call her mother’s cell phone while her mother ran errands, resulting in decreased agitation); and, finally, completing a multifactored evaluation to develop an individualized educational program to increase academic support.

In summary, Jane and her parents benefitted from PEP. Although not all problems were solved by the end of treatment, significant headway had been made, and the family was clearer in knowing how to move forward in managing Jane’s disorder.

John

John was easily distracted and minimally engaged in his first session. He had difficulty writing notes in his treatment workbook and often drew on the materials instead. With much help, John identified goals for his family’s Fix-It List. However, he did not seem to clearly comprehend how they would be helpful to him. In his second session, John began to rub the point of his pencil under his eye. When his therapist appropriately requested he hand over the pencil, John exclaimed, “I can pop your head.” John refused to engage in session content, kicked the therapist, and slammed desk drawers despite redirection and prompts to engage in alternative behaviors. With continued intervention on the part of the therapist, John eventually settled down and the therapist was able to continue the session. By the end of the session, John explained the week’s breathing exercise to his mother. John came to the third session with bright affect, identified and rated his current feeling on the Feeling Thermometer, and correctly reviewed the content of the previous session. Shortly thereafter, however, John became distracted, bored, and began hitting objects in the office with a couch pillow. He was redirectable, frequently apologized for his behavior, and asked with trepidation if the therapist would inform his father of his behaviors. Overall, John was minimally involved in the session but did agree to complete the Healthy Habits project if he did not have to write his activities down in the manual. At the next session, John was unable to describe what he had done on his project, although his father reported John did well with the Healthy Habits activities. Given John’s in-session difficulties with writing, reporting, and staying focused, the therapist, John, and his father agreed to modify the remaining treatment sessions. They agreed John could work on session content without writing information in his workbook, as this often led to off-task behaviors, probably due in part to John’s fine motor difficulties. Additionally, the treatment hour was adapted to spend less time with John alone and more time with John and his parent to review the session topic and discuss the weekly project. During the fifth session, John was significantly more engaged and doubled his participation and effort points from the previous session. John identified and evaluated hurtful and helpful thoughts, feelings, and behaviors on the Thinking-Feeling-Doing activity.

In session six, John had difficulty understanding and applying the Problem Solving activity but put forth significant effort and agreed to work on this project. His father reported that although John has learned breathing techniques to calm down, he refused to apply them. The therapist provided suggestions to help John remember and apply these skills. During the seventh session, given John’s interest in sports, the therapist used a “beating anger” analogy to increase investment in mood and behavior regulation, particularly in applying coping skills to decrease anger and avoid associated negative consequences. John had gained 15 pounds since his last medication change, so in this second review of Healthy Habits he agreed to decrease his food intake and opt for more healthy alternative food choices. John reported back on his progress at the next session. In sessions eight and nine, John readily identified verbal and nonverbal communication skills and discussed their importance in effective communication. He was eager to complete the Paying Attention to Feelings project with his parents. He effectively demonstrated in the verbal communication activity how to change hurtful statements to more helpful, positive ones and listed three activities he would request his parents engage in to improve communication on the Let’s Talk project. In their last session, John and his parents reviewed communication skills and agreed that decreased yelling would be their first step to improve family communication. John reported that, the night before, he was angry about not having a game to play while at work with his mother. He left his mother’s office and stood in the middle of a busy roadway, with an intention to die. After about 10 minutes, John eventually walked over to his mother who had followed him out and was calling him to get off of the road. Given John’s current level of danger to self, the therapist developed a safety plan with John and his parents.

Overall, John had challenges in treatment participation. He was aggressive in the early sessions, although he responded well to revamping of the sessions. John did complete all nine weekly projects, although he had significant difficulty recalling and reporting back on them in the subsequent week. His mood continued to vacillate considerably over the course of treatment.

John’s parents were very involved in treatment. They alternated bringing him to sessions. John’s mother attended each parent session and his father accompanied her to the last parent session. John’s mother often brought in information or asked questions about what she had read on the Internet or viewed on television (e.g., brain imagining techniques to diagnose BPD, the genetic contributions to various disorders). Further, she appeared well informed about educational interventions, as well as John’s medications, due to a well-developed relationship with John’s psychiatrist. Despite an excellent overall knowledge base and agreement with John’s illness and treatment needs, however, John’s parents struggled to manage the family interactions resulting from John’s mood swings and often felt stressed and “burned out.” Therefore, treatment content of the parent sessions was tailored to explicitly address these concerns. John’s parents completed seven of eight weekly projects. They did not complete the Family Fix-It List project but agreed to follow up on that activity at home. The therapist’s time constraints precluded utilization of any in-the-bank sessions.

While in treatment, John damaged his daycare provider’s car, resulting in discontinuation of her services. John’s mother successfully used the Problem Solving project to process this event, which helped her feel more prepared for future calamities. The most significant impact John’s parents reported from PEP was learning to manage their stress better by “allowing” themselves their own time to recharge. They did this by embracing the reframe that dealing with John’s illness was “a marathon, not a sprint.” This concept was originally introduced in session four (while reviewing the Negative Family Cycle and completing the Thinking-Feeling-Doing project) but required time to accept and act upon. This is consistent with earlier clinical trials of PEP, in which continued improvement occurs after treatment ends (Fristad, 2006; Fristad, et al., 2009).

In the sibling session, John’s older brother identified his feelings of anger and disappointment over John’s mood and behavior. He processed his desire to help John “feel better” and identified that he could remind John to use coping skills from his Tool Kit and his breathing techniques. Additionally, he stated it would be helpful for each family member to be heard and have “me time.” The school professional session was conducted over the phone with John’s special education teacher. His teacher reported John often cries without provocation and becomes easily frustrated and irritable. The clinician and John’s teacher reviewed his education plan. John’s teacher was open to interventions to address John’s mood variability and disruptive behaviors. The clinician discussed the need for flexibility and preparing John for changes, as well as how interventions should be consistently available but flexibly employed.

As with Jane, John and his parents benefitted from PEP, although many symptoms remained problematic when treatment ended. This is not unusual when treating children with BPD. Rather than anticipating symptom resolution, a goal is for parents and children to have a sense of how to proceed with ongoing challenges that will continue to emerge as symptoms wax and wane. The sibling and school professional sessions were beneficial in airing concerns and developing several concrete steps that could be employed in each respective setting.

EVALUATING OUTCOME

The postdoctoral study coordinator/therapist conducted baseline assessments while posttreatment assessments were conducted by a reliably trained graduate research associate.

Three of four mood scales assessing current functioning improved from pretreatment to posttreatment. Jane’s K-DRS score declined from 67 to 55 (18% reduction), whereas John’s increased from 43 to 55 (28% increase). Both Jane’s and John’s K-MRS scores declined considerably but remained in the symptomatic range (45 to 28 [38% reduction] and 48 to 28 [42% reduction], respectively).

Jane’s current and worst C-GAS scores at baseline were 36 and 31, while John’s were 35 and 15. C-GAS scores from 31 to 40 represent degrees of major functional impairment in several areas while scores from 41 to 50 represent degrees of moderate interference in functioning in most areas. Scores in the teens indicate severe impairment in functioning across most or all areas of functioning. Following treatment, Jane’s current and worst (since last interview) C-GAS scores were 48 and 41, respectively, while John’s were 40 and 38, respectively. Thus, functioning improved over time, although both children were still notably impaired at the end of the study.

Family functioning improved somewhat, as evidenced by six of eight EEAC scales changing in the desired direction. According to a Wilcoxon signed ranks test, EEAC scores showed a statistically significant tendency toward improvement (z = −2.103, p = .035). Parental attitudes about mental health treatment improved from preintervention to postintervention (Jane’s parents’ scores: M = 3.9, M = 4.2; John’s parents’ scores: M = 3.3, M = 4.2). John’s baseline TBQ-C score was uninterpretable as he completed only one item. Jane’s score declined over time (M = 4.3 to M = 3.8). TBQ-P results reflecting improved beliefs about treatment following PEP are consistent with other findings (Davidson & Fristad, 2006; Mendenhall et al., 2009). Jane’s declining score may have reflected her reluctance to apply new skills as well as her regression at the end of treatment.

Following treatment, three parents and both children completed evaluation forms. The forms utilized a 5-point Likert scale ranging from 1 (Strongly Agree) to 5 (Strongly Disagree). Parents’ results suggested they benefited from the therapist working with the school (M = 1.0), and their child benefited from the sibling session (M = 1.7). Parents also reported being better able to work with the school system (M = 1.3) and that the number of sessions met their family’s need (M = 1.3). The children reported learning more about their mood disorder (M = 1.5), getting along better with their family (M = 2.0), and liking that the therapist talked with their school (M = 1.0) and sibling (M = 1.5). No items received a negative endorsement (lower than a 2.5 rating).

CONCLUSIONS

An expanded version of PEP was piloted with two children to evaluate its clinical utility and feasibility in improving child and family functioning for children with BPD. Results suggest family functioning improved, as did children’s manic symptoms and overall level of functioning. Families also reported PEP assisted them in working with the school. Parents reported the length of treatment was feasible in meeting their treatment needs.

Throughout the assessment and treatment process, both children displayed high levels of resistance. This is not uncommon when treating children with BPD. Despite this, improvement in symptoms and family functioning occurred. This may be related to the format of treatment, which actively engages parents, school professionals, and siblings in addition to the child. This “wraparound” approach may lend itself to treatment gains despite resistance by the child due to others in the child’s life learning and working on skills that may foster improvement.

These cases illustrate how manualized treatments can be implemented with flexibility (Kendall & Beidas, 2007). The children and their families displayed different and varying levels of symptom severity, engagement, knowledge, and follow through. Task demands were adjusted in session, as needed, and the amount of attention devoted to topics was tailored to the families’ concerns. Session content shifted to addressing immediate safety issues and unexpected events such as a suicidal gesture that occurred. In addition, the use of behavior management (i.e., points) during child sessions and the availability of in-the-bank sessions also helped manage challenges that came up during treatment while continuing to cover the specified material.

Study limitations include the small sample. Both children were White and lived in intact families with their biological parents and one sibling. Other family types may respond differently to PEP. Additionally, due to time and personnel constraints, the study had a set end date, precluding more extensive use of in-the-bank sessions. Finally, it is possible that characteristics of families seeking treatment at a clinical research center are not representative of the general clinical population. They may, for example, be more motivated for change or, in the case of these families, the parents, if not the children, may have been highly engaged in and committed to the process of therapy. If PEP is ultimately demonstrated to be beneficial in large-scale randomized clinical trials, effectiveness studies in the general community are needed to demonstrate whether PEP is beneficial under standard clinical parameters.