Predictors of Dropout in Family-Based Psychosocial Treatment for Pediatric Bipolar Disorder: An Exploratory Study
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Family-based psychosocial treatments have been developed to address the significant impairments in psychosocial functioning among youth with pediatric bipolar disorder (PBD), yet factors impacting engagement in these treatments have yet to be extensively studied. Early termination from treatment may lead to negative outcomes among youth with PBD. Thus, the primary aim of this exploratory study was to identify predictors and moderators of treatment dropout in PBD. Drawing from the child attrition literature, this study examined characteristics likely to be associated with dropout in families affected by PBD, including potential targets of treatment. Using Cox proportional hazards regressions, we explored the impact of modifiable parent, child, and family characteristics (i.e., parent stress, family coping, child symptoms) and stable demographic characteristics (i.e., family income, ethnic minority status) on dropout among 59 youth aged 7 to 13 who participated in a randomized clinical trial comparing a manualized psychotherapy for PBD (child- and family-focused cognitive behavioral therapy; CFF-CBT) versus treatment as usual (TAU). Specifically, we explored whether dropout was related to baseline levels and changes in these characteristics over the course of treatment in CFF-CBT versus TAU. Findings provide preliminary support for high parental stress as a predictor of dropout across treatments and low baseline parent coping as a predictor of retention in CFF-CBT specifically. Worsening of child depression symptoms over treatment predicted greater likelihood of dropout in CFF-CBT. Finally, improvement in children’s global functioning was associated with reduced dropout across treatments. Results have important implications for tailoring interventions for PBD.
KeywordsPediatric bipolar disorder Dropout Attrition Premature termination Treatment
This study was funded by the National Institute of Mental Health (K23 MH079935) and the American Foundation for Suicide Prevention (YIG1-140-11).
Compliance with Ethical Standards
Conflict of Interest
Ashley Isaia declares that she has no conflict of interest. Sally Weinstein has received funding from the American Foundation for Suicide Prevention (YIG1-140-11) and receives royalties from Oxford University Press. Stewart Shankman declares he has no conflict of interest. Amy West has received funding from the National Institutes of Mental Health (K23 MH079935) and receives royalties from Oxford University Press.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards
Informed consent was obtained from all individual participants included in the study.
- Armbruster, P., & Kazdin, A. (1994). Attrition in child psychotherapy. In T. Ollendick & R. Prinz (Eds.), Advances in clinical child psychology (Vol. 16, pp. 81–108). New York, NY: Plenum.Google Scholar
- Berkowitz, S. J. (2003). Children exposed to community violence: The rationale for early intervention. Clinical Child and Family Psychology Review, 6, 293–302. https://doi.org/10.1023/B:CCFP.0000006295.54479.3d.CrossRefPubMedGoogle Scholar
- Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 521–529. https://doi.org/10.1097/00004583-199305000-00006.CrossRefGoogle Scholar
- Conners, C., & March, J. (1996). The Conners-March developmental questionnaire. Toronto, ON: MultiHealth Systems Inc.Google Scholar
- Derogatis, L. R. (1996). Symptom Checklist-90-R: Administration, scoring, and procedures manual. Minneapolis, MN: National Computer Systems, Inc.Google Scholar
- Donenberg, G. R., & Pao, M. (2005). Youths and HIV/AIDS: Psychiatry’s role in a changing epidemic. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 728–747. https://doi.org/10.1097/01.chi.0000166381.68392.02.CrossRefGoogle Scholar
- Fristad, M. A., Verducci, J. S., Walters, K., & Young, M. E. (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66, 1013–1021. https://doi.org/10.1001/archgenpsychiatry.2009.112.CrossRefPubMedGoogle Scholar
- Geller, B., Bolhofner, K., Craney, J. L., Williams, M., DelBello, M. P., & Gundersen, K. (2000). Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 1543–1548. https://doi.org/10.1097/00004583-200012000-00018.CrossRefGoogle Scholar
- Geller, B., Craney, J. L., Bolhofner, K., Nickelsburg, M. J., Williams, M., & Zimerman, B. (2002). Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry, 159, 927–933. https://doi.org/10.1176/appi.ajp.159.6.927.CrossRefPubMedGoogle Scholar
- Geller, B., Zimerman, B., Williams, M., Bolhofner, K., Craney, J. L., DelBello, M. P., & Soutullo, C. (2001). Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 450–455. https://doi.org/10.1097/00004583-200104000-00014.CrossRefGoogle Scholar
- Goldman-Mellor, S. J., Caspi, A., Harrington, H., Hogan, S., Nada-Raja, S., Poulton, R., & Moffitt, T. E. (2014). Suicide attempt in young people: A signal for long-term health care and social needs. JAMA Psychiatry, 71, 119–127. https://doi.org/10.1001/jamapsychiatry.2013.2803.CrossRefPubMedPubMedCentralGoogle Scholar
- Goldstein, T. R., Birmaher, B., Axelson, D., Ryan, N. D., Strober, M. A., Gill, M. K., & Keller, M. (2005). History of suicide attempts in pediatric bipolar disorder: Factors associated with increased risk. Bipolar Disorders, 7, 525–535. https://doi.org/10.1111/j.1399-5618.2005.00263.x.CrossRefPubMedPubMedCentralGoogle Scholar
- Hauser, M., Galling, B., & Correll, C. U. (2013). Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: A systematic review of prevalence and incidence rates, risk factors, and targeted interventions. Bipolar Disorders, 15, 507–523. https://doi.org/10.1111/bdi.12094.CrossRefPubMedPubMedCentralGoogle Scholar
- Horwitz, S., Demeter, C., Hayden, M., Storfer-Isser, A., Frazier, T. W., Fristad, M. A., & Axelson, D. (2012). Parents’ perceptions of benefit of children’s mental health treatment and continued use of services. Psychiatric Services, 63, 793–801. https://doi.org/10.1176/appi.ps.201100460a.CrossRefPubMedGoogle Scholar
- Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman Brief IntelligenceTest–Second Edition (KBIT-2). Circle Pines, MN: American Guidance Service.Google Scholar
- Keenan-Miller, D., Peris, T., Axelson, D., Kowatch, R. A., & Miklowitz, D. J. (2012). Family functioning, social impairment, and symptoms among adolescents with bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 1085–1094. https://doi.org/10.1016/j.jaac.2012.08.005.CrossRefGoogle Scholar
- Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003). Bipolar disorder in adolescents: Epidemiology and suicidal behavior. In B. Geller, M. P. DelBello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 7–24). New York, NY: Guilford.Google Scholar
- MacPherson, H. A., Weinstein, S. M., Henry, D. B., & West, A. E. (2016). Mediators in the randomized trial of Child-and Family-Focused Cognitive-Behavioral Therapy for pediatric bipolar disorder. Behaviour Research and Therapy, 85, 60–71. https://doi.org/10.1016/j.brat.2016.08.014.CrossRefPubMedPubMedCentralGoogle Scholar
- McClellan, J., Kowatch, R., & Findling, R. L. (2007). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 107–125. https://doi.org/10.1097/01.chi.0000242240.69678.c4.CrossRefGoogle Scholar
- McCubbin, H. I., McCubbin, M. A., Patterson, J. M., Cauble, A. E., Wilson, L. R., & Warwick, W. (1983). CHIP-coping health inventory for parents: An assessment of parental coping patterns in the care of the chronically ill child. Journal of Marriage and Family, 45, 359–370. https://doi.org/10.2307/351514.CrossRefGoogle Scholar
- McCubbin, H. I., Olson, D. H., & Larsen, A. S. (1991). F-COPES: Family crisis oriented personal evaluation scales. In H. I. McCubbin, & A. I. Thompson (Eds.), Family assessment inventories for research and practice (2nd ed., pp. 203–218). Madison, Wisconsin: University of Wisconsin-Madison.Google Scholar
- Miklowitz, D. J., Axelson, D. A., Birmaher, B., George, E. L., Taylor, D. O., Schneck, C. D., & Brent, D. A. (2008). Family-focused treatment for adolescents with bipolar disorder: Results of a 2-year randomized trial. Archives of General Psychiatry, 65, 1053–1061. https://doi.org/10.1001/archpsyc.65.9.1053.CrossRefPubMedPubMedCentralGoogle Scholar
- Miklowitz, D. J., Axelson, D. A., George, E. L., Taylor, D. O., Schneck, C. D., Sullivan, A. E., & Birmaher, B. (2009). Expressed emotion moderates the effects of family-focused treatment for bipolar adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 643–651. https://doi.org/10.1097/CHI.0b013e3181a0ab9d.CrossRefGoogle Scholar
- Miklowitz, D. J., George, E. L., Axelson, D. A., Kim, E. Y., Birmaher, B., Schneck, C., & Brent, D. A. (2004). Family-focused treatment for adolescents with bipolar disorder. Journal of Affective Disorders, 82, S113–S128. https://doi.org/10.1016/j.jad.2004.05.020.CrossRefPubMedPubMedCentralGoogle Scholar
- Pavuluri, M. N., Birmaher, B., & Naylor, M. W. (2005). Pediatric bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 846–871. https://doi.org/10.1097/01.chi.0000170554.23422.c1.CrossRefGoogle Scholar
- Pellerin, K. A., Costa, N. M., Weems, C. F., & Dalton, R. F. (2010). An examination of treatment completers and non-completers at a child and adolescent community mental health clinic. Community Mental Health Journal, 46, 273–281. https://doi.org/10.1007/s10597-009-9285-5.CrossRefPubMedGoogle Scholar
- Perlis, R. H., Miyahara, S., Marangell, L. B., Wisniewski, S. R., Ostacher, M., & DelBello, M. P., STEP-BD Investigators. (2004). Long-term implications of early onset in bipolar disorder: Data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biological Psychiatry, 55, 875–881. https://doi.org/10.1016/j.biopsych.2004.01.022.CrossRefPubMedGoogle Scholar
- Pina, A. A., Silverman, W. K., Weems, C. F., Kurtines, W. M., & Goldman, M. L. (2003). A comparison of completers and noncompleters of exposure-based cognitive and behavioral treatment for phobic and anxiety disorders in youth. Journal of Consulting and Clinical Psychology, 71, 701. https://doi.org/10.1037/0022-006X.71.4.701.CrossRefPubMedGoogle Scholar
- Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704.CrossRefPubMedGoogle Scholar
- Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A Children’s Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 1228–1231. https://doi.org/10.1001/archpsyc.1983.01790100074010.CrossRefPubMedGoogle Scholar
- Townsend, L. D., Demeter, C. A., Youngstrom, E., Drotar, D., & Findling, R. L. (2007). Family conflict moderates response to pharmacological intervention in pediatric bipolar disorder. Journal of Child and Adolescent Psychopharmacology, 17, 843–852. https://doi.org/10.1089/cap.2007.0046.CrossRefPubMedGoogle Scholar
- U.S. Department of Health and Human Services, National Institute of Mental Health (2015). NIMH strategic plan for research (NIH Publication No. 15-6368). http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml.
- Weinstein, S. M., Cruz, R. A., Isaia, A. R., Peters, A. T., & West, A. E. (2017). Child- and family-focused cognitive behavioral therapy for pediatric bipolar disorder: Applications for suicide prevention. Suicide and Life-Threatening Behavior. https://doi.org/10.1111/sltb.12416.
- Weinstein, S. M., Henry, D. B., Katz, A. C., Peters, A. T., & West, A. E. (2015). Treatment moderators of child-and family-focused cognitive-behavioral therapy for pediatric bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 116–125. https://doi.org/10.1016/j.jaac.2014.11.007.CrossRefGoogle Scholar
- Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., & Martin, J. (2012). Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: A randomized effectiveness trial. Archives of General Psychiatry, 69, 274–282. https://doi.org/10.1001/archgenpsychiatry.2011.147.CrossRefPubMedGoogle Scholar
- Weisz, J. R., Doss, A. J., & Hawley, K. M. (2005). Youth psychotherapy outcome research: A review and critique of the evidence base. Annual Review of Psychology, 56, 337–363. https://doi.org/10.1146/annurev.psych.55.090902.141449.CrossRefPubMedGoogle Scholar
- West, A. E., Jacobs, R. H., Westerholm, R., Lee, A., Carbray, J., Heidenreich, J., & Pavuluri, M. N. (2009). Child and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Pilot study of group treatment format. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 18, 239.PubMedPubMedCentralGoogle Scholar
- West, A. E., & Weinstein, S. M. (2011). A family-based psychosocial treatment model. The Israel Journal of Psychiatry and Related Sciences, 49, 86–93.Google Scholar
- West, A. E., Weinstein, S. M., Peters, A. T., Katz, A. C., Henry, D. B., Cruz, R. A., & Pavuluri, M. N. (2014). Child-and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: A randomized clinical trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 1168–1178.e1161. https://doi.org/10.1016/j.jaac.2014.08.013.CrossRefGoogle Scholar
- Wier, L. M., Pfuntner, A., Maeda, J., Stranges, E., Ryan, K., et al. (2011). HCUP facts and figures: Statistics on hospital-based care in the United States, 2009. http://www.hcup-us.ahrq.gov/reports.jsp.