Bipolar Disorders in Children and Adolescents

Naomi A. Schapiro, RN, MS, CPNP

Disclosures

J Pediatr Health Care. 2005;19(3):131-141. 

In This Article

Nonpharmacologic Treatment

The goals of a therapeutic relationship for the child with BPD are to (a) recognize symptoms and dysfunction early so that effective intervention can control symptoms, (b) prevent deterioration, and (c) promote healthy development and optimal functioning (Kusumakar et al., 2002). Building such a relationship is no easy task: older children and adolescents may be resistant to treatment, and families may have been drained by both the child's symptoms and by the "often protracted pathway into appropriate care" (Kusumakar et al., p. 117). Several studies have shown that high levels of critical, hostile, or emotionally overinvolved attitudes in parents or spouses (also known as high expressed emotion) are associated with higher rates of relapse and poor symptomatic outcomes in adults with BPD, confirming outcomes previously associated with schizophrenia (Miklowitz, Simoneau, George, Richards, Kalbag, et al., 2000). Multifamily psychoeducation groups for preadolescent children with BPD have been shown to be effective in one randomized controlled trial (Fristad, Gavazzi, & Mackinaw-Koons, 2003). Treatment children report significant gains in social support from their parents and peers, and treatment families report increased knowledge and ability to obtain appropriate services. An open trial of child-focused and family-focused cognitive behavioral therapy has been found to significantly decrease symptoms in children ages 5 to 17 years who are taking stabilizing medications, including children with coexisting conditions such as ADHD (Pavuluri, Graczyk, et al., 2004).

Unfortunately, many families lack the economic resources or insurance coverage to access comprehensive mental health services for their children (Melnyk et al., 2003; Simpson et al., 2002). Respected researchers in Missouri (Geller et al., 1998) note as a limitation to their studies the lack of psychiatric services for publicly insured or uninsured children. In a nationwide review of private health insurance, Fox, McManus and Reichman (2003) found that only 2% of plans nationwide would cover all recommended services for an adolescent with BPD and substance abuse, and many plans would specifically exclude the family groups found to be effective by Fristad and colleagues (2003). Sean's parents are likely to find coverage for at least diagnosis and initial treatment, whether he turns out to have a mood disorder, substance abuse or both, and a dual diagnosis might increase his eligibility for services (Fox et al.). But Marina, who is already considering discontinuing some of her medications, may not have the coverage for either long-term psychiatric follow-up or a psychoeducational group involving her family.

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