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Treating the Ups & Downs of Bipolar Children
Bipolar Children  continuing education addiction counselor CEUs

Section 24
The RAINBOW Method for Treating Pediatric Bipolar Disorder

CEU Question 24 | CEU Answer Booklet | Table of Contents | Bipolar
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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
The article above contains foundational information. Articles below contain optional updates.

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.

Online Continuing Education QUESTION 24
According to Pavuluri, what are two distinctive features of the RAINBOW treatment model? Record the letter of the correct answer the CEU Answer Booklet.

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