Adolescent and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorders: An Open Trial and Individual Trajectories Study in Routine Psychiatric Care.

Psychosocial treatments improve outcome in Pediatric bipolar disorder (PBD), but few are developed specifically for adolescents and none has been evaluated in Europe. This study evaluates family-focused cognitive-behavioral therapy for adolescents (ages 13-18) with PBD in routine psychiatric care in Sweden, adapted for teenagers in a European setting from the Child and Family-Focused Cognitive Behavioral Therapy for PBD (ages 8-12) developed in the US. In a repeated-measure open trial, psychosocial functioning, depression, skills and knowledge about PBD, and family climate were assessed at pre-treatment, post-treatment, and after 6 months. Assessments were made by adolescents (n = 45), parents (n = 61) and clinicians. Both group statistics and individual trajectories are reported. Psychosocial function, as rated by parents and clinicians, improved at post-treatment, and parents reported less mania and improved family climate at post-treatment. Both parents and adolescents reported improved skills and knowledge. Most results after treatment showed medium effect sizes. Significant improvements were seen in most individual trajectories, however no change and even deterioration was observed in some. The present trial shows that AFF-CBT is well accepted and associated with improved psychosocial function in adolescents and improved skills and knowledge about PBD in adolescents and their parents. Regarding mood symptoms and family climate the results showed more individual variability, indicating that adjustments in delivery of the treatment according to the unique patient could be of importance. AFF-CBT seems to be a valuable addition to pharmacological treatments in PBD.

Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care.

Restraints and seclusions are restrictive interventions used in psychiatric inpatient units when there is an imminent risk of harm to the patient or others. Coercive measures are controversial and can lead to negative consequences, including negative emotions, re-traumatization, injuries, or death. The article summarizes the last 10 years of literature regarding methods and strategies used for reducing seclusions and restraints in child and adolescent psychiatric inpatient units, and reports on their outcomes. The literature was reviewed by searching PubMed and PsycInfo for English-language articles published between May 2010 and May 2020. Eighteen articles were found that described methods or strategies aimed at reducing restraint or seclusion utilization in child and adolescent psychiatric inpatient units. The following interventions were evaluated: Trauma-Informed Care (TIC), Six Core Strategies, Child and Family Centered Care (CFCC), Collaborative & Proactive Solutions (CPS), Strength-Based Care, Modified Positive Behavioral Interventions and Supports (M-PBIS), Behavioral Modification Program (BMP), Autism Spectrum Disorder Care Pathway (ASD-CP), Dialectical Behavior Therapy (DBT), sensory rooms, Mindfulness-Based Stress Reduction Training (MBSR) of staff, and Milieu Nurse-Client Shift Assignments. Most of the interventions reduced the use of seclusions and/or restraints. Two child-centered and trauma-informed initiatives eliminated the use of mechanical restraints. This review shows that the use of coercive measures can be reduced and should be prioritized. Successful implementation requires ongoing commitment on all levels of an organization and a willingness to learn. To facilitate comparisons, future models should evaluate different standardized parameters.

Acute Mania and Catatonia in a Teenager Successfully Treated with Electroconvulsive Therapy and Diagnosed with Turner Syndrome and Bipolar Disorder.

BACKGROUND: Turner syndrome (TS) is an X-linked chromosomal abnormality with a global prevalence of 1/2000 live-born girls. The physiological symptoms of TS have been thoroughly characterized, but only a few studies have described associated psychiatric symptoms. We report a case of an adolescent girl who presented with acute mania with psychotic features and was successfully treated with electroconvulsive therapy (ECT). She was subsequently diagnosed with bipolar syndrome and TS. Case Presentation. A 17-year-old girl presented to us with manic symptoms, including disorganized speech, auditory hallucinations, and affect lability. Initially, she was treated with antipsychotics and benzodiazepines, whereby the positive affective symptoms declined. However, the psychotic symptoms progressed, and she developed a catatonic state. ECT was started 6 days after admission, with improvement after two treatments. When ECT was tapered after seven sessions, she relapsed, and the treatment was extended to twelve sessions, with successful outcome. Following discharge, she was diagnosed with TS with partial loss on one of the X-chromosomes (46X, del (X)(p21)), which might have contributed to the development of her sudden acute manic episode. CONCLUSIONS: This case demonstrates for the first time that ECT may be a safe and efficient treatment strategy for acute mania in adolescents with concomitant TS and that severely affected adolescents may require a prolonged series with gradual tapering of ECT. The present case also demonstrates a possible association between TS and bipolar syndrome and that the clinical presentation of a manic episode in a patient with this comorbidity could be more complex and the treatment response slower.

Electroconvulsive therapy for manic state with mixed and psychotic features in a teenager with bipolar disorder and comorbid episodic obsessive-compulsive disorder: a case report.

BACKGROUND: Comorbidity of bipolar disorder and obsessive-compulsive disorder is common in adolescence. Obsessive-compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific features. Management of pediatric bipolar disorder-obsessive-compulsive disorder is challenging, as pharmacotherapy of obsessive-compulsive disorder may induce or exacerbate manic episodes and there is limited evidence of treatment efficacy. Electroconvulsive therapy is sparsely used in children and adolescents, but is documented to be a safe and efficacious intervention in adults with bipolar disorder. In view of the severity of symptoms in juvenile mania, studies on treatment strategies are warranted. We report a case of an adolescent with bipolar disorder-obsessive-compulsive disorder who was successfully treated with electroconvulsive therapy during an episode of severe mania. CASE PRESENTATION: A 16-year-old girl of Middle East origin first presented to us with depressed mood, irritability, and increased obsessive-compulsive disorder symptoms, which were initially interpreted in the context of acute stress secondary to migration. She had been diagnosed with bipolar disorder and obsessive-compulsive disorder in her previous home country, but had difficulties in accounting for earlier psychiatric history. During hospitalization her mood switched to a manic state with mixed and psychotic features, at times showing aggression toward others. Interruption in her lithium treatment for a short period and possibly the introduction of an atypical antipsychotic could in part have been triggering factors. After 8 weeks of in-patient care and psychotropic drug trials, electroconvulsive therapy was initiated and administered every second or third day for 4 weeks, with marked positive response. No apparent side effects were reported. CONCLUSIONS: This case demonstrates the need for a detailed medical history, taking special note of periodicity and character of obsessive-compulsive disorder symptoms, in adolescents with mood disorders. When treating culturally diverse patients, extra consideration should be taken. Special concerns in the pharmacological treatment to avoid the patient's condition from worsening must be addressed, including giving priority to mood stabilization before obsessive-compulsive disorder symptoms. There are potential benefits in considering electroconvulsive therapy in young patients with severe mania where first-line treatment options have failed.

Adolescent and Family-focused Cognitive-behavioural Therapy for Paediatric Bipolar Disorders: A Case Series.

Although pharmacological treatments can help alleviate mood symptoms in youth with paediatric bipolar disorder (PBD), residual symptoms still commonly persist. In many cases, these symptoms seriously affect the social and psychological development of children and adolescents suffering from PBD. Complementary interventions, such as psychosocial and psychoeducational treatments, can help children and their families manage mood regulation and other challenges throughout childhood and adolescence. However, most research on such interventions has focused on children, single-family psychoeducation, and individual cognitive behavioural therapy. The present study, conducted in Sweden, used a case-series design to explore whether child- and family-focused cognitive behavioural therapy (CFF-CBT) for PBD, adapted from children (8-12 years) to adolescents (13-18 years) and applied in a multi-family format, could help reduce symptoms, improve psychosocial functioning, increase parents' knowledge of and skills for coping with the disorder, and improve family expressed emotion for adolescents with PBD. Furthermore, we aimed to assess whether the effects of such CFF-CBT are maintained at a one-year follow-up. Seven adolescents and 11 parents in two multi-family groups received twelve sessions of CFF-CBT. Self-rating questionnaires and clinical observations were used to evaluate clinically significant changes for individual cases. The results suggest that CFF-CBT is feasible to deliver in an outpatient psychiatric setting and may be effective for developing parents' skills and knowledge for coping with PBD, increasing adolescents' psychosocial functioning, and improving family climate. The results are in line with previous findings on CFF-CBT for children with PBD, suggesting that CFF-CBT is a valuable adjunctive treatment for adolescents with PBD. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Preliminary evidence indicates that CFF-CBT (RAINBOW) is both acceptable and an important complement to pharmacological treatment for adolescents suffering from paediatric bipolar disorder (PBD). Adolescent PBD populations show a high degree of comorbidity and individual clinical presentations that influence treatment results. Families show a large variation in ability to participate and benefit from RAINBOW treatment. Assessing and addressing pre-treatment environmental stressors and family climate during treatment is important for optimizing treatment effect. Symptoms of PBD fluctuate and new episodes can occur spontaneously. It is therefore important to follow PBD symptoms over time to draw more precise conclusions on treatment effects. When assessing treatment effects on psychiatric symptoms, social functioning, and family climate, it is important to use multiple rating sources, as ratings can vary considerably between adolescents, parents, and clinicians.