Bipolar disorder (BD) in children is a complex and severely impairing childhood disorder that has received increasing attention from the psychiatric community in recent years. The accurate phenomenology and characterization of pediatric bipolar disorder (PBD) has been the focus of both empirical investigation and extensive discussion among professionals as the field has endeavored to better understand PBD and its differentiation from other childhood disorders. A bipolar spectrum disorder is diagnosed based on the presence of episodes of either extreme irritability or elevated, expansive mood in combination with other symptoms, including grandiosity, decreased need for sleep, hypersexuality, depressed mood, racing thoughts, and impulsive behavior. Diagnosing PBD requires careful assessment of discrete mood episodes, with sensitivity to the developmental manifestation of symptoms. PBD is distinctive in that, compared to the typical adult presentation of bipolar disorder, children tend to experience longer episodes with rapid-cycling patterns and symptoms of mixed mood states (Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003). In addition, the diagnosis of PBD is often complicated by significant heterogeneity in symptom presentation and frequent co-occurring disorders, such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and anxiety disorders.

Recent research has begun to investigate the neurological underpinnings of the various symptoms and functional impairments observed in PBD. Relative to healthy controls and, in some cases, to children with other psychiatric disorders, children with PBD demonstrate impairments in cognitive domains associated with learning, problem solving, and cognitive/emotional modulation, including attention, working memory, executive function, verbal memory, and processing speed (Bearden et al., 2006; Dickstein et al., 2004; Dickstein et al., 2007; Doyle et al., 2005; Henin et al., 2007; McClure et al., 2005; Pavuluri, Schenkel, et al., 2006). These neurocognitive impairments persist over time (Pavuluri, West, Hill, Jindal, & Sweeney, 2009) and occur independent of mood state (Pavuluri, Schenkel, et al., 2006). Passarotti and Pavuluri (2011) proposed an integrated neurobiological model involving altered functioning of the brain circuits responsible for response inhibition, reward, and executive functioning. This model differentiates the pathogenesis of symptoms and impairments in PBD from common co-occurring disorders like ADHD and explains how dysfunction of the brain mechanisms involved in these systems contributes to the affect dysregulation, low frustration tolerance, impulsivity, and maladaptive reward seeking implicated in cognitive, social, and academic impairments (Passarotti & Pavuluri, 2011).

PBD symptoms are associated with chronic and significant impairments in all domains of psychosocial functioning—individual, family, peer, and school/community. Likely due, in part, to the differences in brain functioning and neurocognitive deficits just described, children with PBD demonstrate academic underperformance, including problems with math and reading (Henin et al., 2007; Pavuluri, O’Connor, Harral, Moss, & Sweeney, 2006), and disruptive school behavior (Geller, Zimerman, et al., 2002). In addition, peer relationships are characterized by limited peer networks, peer victimization, and poor social skills (Geller, Craney, et al., 2002; Wilens et al., 2003). Poor family functioning complicates family support. PBD children often experience strained sibling and parent relationships (Geller et al., 2000; Wilens et al., 2003), characterized by less warmth, affection, and intimacy and more fighting, forceful punishment, and conflict (Schenkel, West, Harral, Patel, & Pavuluri, 2008). These negative experiences accumulate throughout childhood. In adolescence, youth with PBD exhibit low self-esteem, hopelessness, external locus of control, and maladaptive coping strategies (Rucklidge, 2006), poor social functioning (Goldstein, Miklowitz, & Mullen, 2006), high expressed emotion in family relationships and more negative life events and chronic stress in the context of family life (Kim, Miklowitz, Biuckians, & Mullen, 2007), and lower levels of family adaptability and cohesion as a function of aggressive behavior (Keenan-Miller, Peris, Axelson, Kowatch, & Miklowitz, 2012).

The severity of symptoms and accumulation of psychosocial risk throughout development renders PBD a significant public health concern. Children with PBD experience high rates of repeated hospitalization and suicide attempts (Lewinsohn, Olino, & Klein, 2005). In adulthood, PBD patients demonstrate greater mental health care utilization, elevated rates of other chronic disease and health conditions, lower rates of school graduation, and loss of work days and career productivity (Kessler et al., 2006; Kupfer, 2005; Lewinsohn et al., 2005). Thus, PBD places a considerable burden on educational, occupational, and health care systems, not to mention the human cost of loss of individual potential and sense of self, damaged personal relationships, family dysfunction, and suicide. The significant psychosocial deficits and poor long-term prognosis for children with PBD if left untreated (or undertreated) makes high-quality, evidence-based psychosocial treatment an important component of a comprehensive treatment approach. Evidence-based psychosocial methods can be implemented adjunctive to pharmacotherapy to enhance immediate treatment outcomes, improve psychosocial functioning and quality of life, and optimize the global functioning and long-term remission of symptoms for youth with PBD.

Several psychosocial treatment models have been developed and have evidence to support their efficacy. Child- and family-focused cognitive behavioral treatment (CFF-CBT), multifamily psychoeducation groups (MFPGs), and individual family psychoeducation (IFP) have been developed for younger children (7–13), while family-focused treatment (FFT), dialectical behavioral treatment (DBT), and interpersonal and social rhythms therapy (IPSRT) have been developed for adolescents.

The complex constellation of impairments and negative prognostic indicators associated with PBD places a large burden on the families of affected children to help intervene during this period of significant risk. As caregivers of children with PBD, parents bear a great responsibility to help children seek out treatment resources, attend and adhere to treatment, and reinforce treatment goals outside of sessions. However, families often have difficulty helping to effectively manage their child’s illness because of problematic, chaotic, or unsupportive family dynamics. Families of bipolar children report low levels of cohesion, expressiveness, and family activity and high levels of family conflict (Belardinelli et al., 2008; Schenkel et al., 2008). These unstable family dynamics are associated with adverse treatment outcomes. Indeed, a study of pharmacological intervention for children and adolescents with BD found that youth with high levels of family conflict, particularly poor family problem solving, were less likely to benefit from treatment (Townsend, Demeter, Youngstrom, Drotar, & Findling, 2007). In an adjunctive psychosocial FFT study, expressed emotion moderated treatment outcome such that patients of families high in expressed emotion required a more intensive psychosocial intervention to achieve symptomatic improvement than patients of families low in expressed emotion (Miklowitz et al., 2009). In addition, when caregivers of adults with BD experience a high burden, patient adherence and outcome in pharmacological treatment is adversely affected (Perlick et al., 2004). Collectively, these outcomes suggest that assessment of family dynamics provides valuable information for treatment approach and that it is critically important to provide families with the necessary tools to cope with and manage their child’s illness.

Recognizing the important role of the family in PBD, several existing psychosocial treatment modalities include the family and utilize strategies to improve family functioning, involvement, and understanding. Psychoeducation is the core of family involvement in treatment. Prior to the introduction of specific skills training, it is important for family members to develop an understanding of PBD and the impact parent and family systems have on its course of illness. More specifically, parents are educated about the nature of mood episodes, risk factors, and comorbidity as well as the role of medications in treatment, how to monitor safety and side effects, and how to navigate the mental health care and educational systems (Fristad et al., 2002). Although IFP and family psychoeducation groups devote the most time to these concepts throughout treatment, psychoeducation is the foundation of other family-based treatment methodologies, such as CFF-CBT and FFT-A, and forms the basis for further skills training (Miklowitz, 2012; West & Weinstein, 2012).

In addition to enhancing parental knowledge and insight regarding PBD, an essential component to treatment gains is boosting parenting efficacy. Boosting parenting efficacy is achieved through the development of affect regulation strategies, both for the parents and children, as well as behavior management and coping strategies. Specific skills in these domains include self-monitoring of mood states, recognizing and labeling feelings, and managing responses to expansive, negative, and irritable moods. Despite their different theoretical underpinnings, psychoeducation interventions, CFF-CBT, and FFT-A each incorporates affect and behavioral regulation strategies into its treatment model (Fristad et al., 2002; Miklowitz, 2012; West & Weinstein, 2012).

It is also especially important to provide parents with support and help them cope with the burden of managing their child’s illness. To achieve this goal, several family-based interventions have parent-only sessions, designed to allow parents to process difficult feelings, learn the importance of good self-care, and identify strong social supports. CFF-CBT involves intensive work with the parents parallel to the work with children that addresses the parents’ own therapeutic needs and helps them develop an effective parenting style for their child (West & Weinstein, 2012). Similarly, the content covered in parent-only psychoeducation sessions is intended to give parents specific strategies to cope with the variety of challenges associated with their child’s illness (Fristad et al., 2002). Although FFT-A is not designed to work with the family individually, the intervention addresses the therapeutic needs of family members by working with the patient and family together throughout treatment to try to decrease family conflict and enhance family communication surrounding the patient’s illness (Miklowitz, 2012).