Abstract
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.
Similar content being viewed by others
References
Armbruster, P.., & Fallon, T.. (1994). Clinical, sociodemographic, and systems risk factors for attrition in a children’s mental health clinic. American Journal of Orthopsychiatry, 64(4), 577. https://doi.org/10.1037/h0079571.
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.
Belardinelli, C., Hatch, J. P., Olvera, R. L., Fonseca, M., Caetano, S. C., Nicoletti, M., & Soares, J. C. (2008). Family environment patterns in families with bipolar children. Journal of Affective Disorders, 107(1–3), 299–305. https://doi.org/10.1016/j.jad.2007.08.011.
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.
Berry, J. O., & Jones, W. H. (1995). The parental stress scale: Initial psychometric evidence. Journal of Social and Personal Relationships, 12, 463–472. https://doi.org/10.1177/0265407595123009.
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.
Breslau, J., Lane, M., Sampson, N., & Kessler, R. C. (2008). Mental disorders and subsequent educational attainment in a US national sample. Journal of Psychiatric Research, 42, 708–716. https://doi.org/10.1016/j.jpsychires.2008.01.016.
Brookman-Frazee, L., Haine, R. A., Gabayan, E. N., & Garland, A. F. (2008). Predicting frequency of treatment visits in community-based youth psychotherapy. Psychological Services, 5, 126 https://doi.org/10.1037/1541-1559.5.2.126.
Chasson, G. S., Vincent, J. P., & Harris, G. E. (2008). The use of symptom severity measured just before termination to predict child treatment dropout. Journal of Clinical Psychology, 64, 891–904. https://doi.org/10.1002/jclp.20494.
Conners, C., & March, J. (1996). The Conners-March developmental questionnaire. Toronto, ON: MultiHealth Systems Inc.
Costello, E. J., Pine, D. S., Hammen, C., March, J. S., Plotsky, P. M., Weissman, M. M., & Leckman, J. F. (2002). Development and natural history of mood disorders. Biological Psychiatry, 52(6), 529–542. https://doi.org/10.1016/S0006-3223(02)01372-0.
de Haan, A. M., Boon, A. E., de Jong, J. T., Hoeve, M., & Vermeiren, R. R. (2013). A meta-analytic review on treatment dropout in child and adolescent outpatient mental health care. Clinical Psychology Review, 33, 698–711. https://doi.org/10.1016/j.cpr.2013.04.005.
Derogatis, L. R. (1996). Symptom Checklist-90-R: Administration, scoring, and procedures manual. Minneapolis, MN: National Computer Systems, Inc.
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.
Faraone, S. V., Glatt, S. J., & Tsuang, M. T. (2003). The genetics of pediatric-onset bipolar disorder. Biological Psychiatry, 53, 970–977. https://doi.org/10.1016/S0006-3223(02)01893-0.
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.
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.
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.
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.
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.
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.
Goldstein, T. R., Miklowitz, D. J., & Mullen, K. L. (2006). Social skills knowledge and performance among adolescents with bipolar disorder. Bipolar Disorders, 8, 350–361. https://doi.org/10.1111/j.1399-5618.2006.00321.x.
Gopalan, G., Goldstein, L., Klingenstein, K., Sicher, C., Blake, C., & McKay, M. M. (2010). Engaging families into child mental health treatment: Updates and special considerations. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 19, 182.
Gore, F. M., Bloem, P. J., Patton, G. C., Ferguson, J., Joseph, V., Coffey, C., & Mathers, C. D. (2011). Global burden of disease in young people aged 10–24 years: A systematic analysis. The Lancet, 377, 2093–2102. https://doi.org/10.1016/S0140-6736(11)60512-6.
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.
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.
Ingoldsby, E. M. (2010). Review of interventions to improve family engagement and retention in parent and child mental health programs. Journal of Child and Family Studies, 19, 629–645. https://doi.org/10.1007/s10826-009-9350-2.
Kaufman, A. S., & Kaufman, N. L. (2004). Kaufman Brief IntelligenceTest–Second Edition (KBIT-2). Circle Pines, MN: American Guidance Service.
Kazdin, A. E. (1996). Dropping out of child psychotherapy: Issues for research and implications for practice. Clinical Child Psychology and Psychiatry, 1, 133–156. https://doi.org/10.1177/1359104596011012.
Kazdin, A. E., & Mazurick, J. L. (1994). Dropping out of child psychotherapy: Distinguishing early and late dropouts over the course of treatment. Journal of Consulting and Clinical Psychology, 62, 1069.https://doi.org/10.1037/0022-006X.62.5.1069.
Keenan-Miller, D., & Miklowitz, D. J. (2011). Interpersonal functioning in pediatric bipolar disorder. Clinical Psychology: Science and Practice, 18, 342–356. https://doi.org/10.1111/j.1468-2850.2011.01266.x.
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.
Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., & Rahman, A. (2011). Child and adolescent mental health worldwide: Evidence for action. The Lancet, 378, 1515–1525. https://doi.org/10.1016/S0140-6736(11)60827-1.
Kim, E. Y., Miklowitz, D. J., Biuckians, A., & Mullen, K. (2007). Life stress and the course of early-onset bipolar disorder. Journal of Affective Disorders, 99, 37–44. https://doi.org/10.1016/j.jad.2006.08.022.
Krausz, M., Müller-Thomsen, T., & Haasen, C. (1995). Suicide among schizophrenic adolescents in the long-term course of illness. Psychopathology, 28, 95–103. https://doi.org/10.1159/000284906.
Kutcher, S., & McDougall, A. (2009). Problems with access to adolescent mental health care can lead to dealings with the criminal justice system. Paediatrics & Child Health, 14, 15–18. https://doi.org/10.1093/pch/14.1.15.
Leverich, G. S., Post, R. M., Keck, P. E., Altshuler, L. L., Frye, M. A., Kupka, R. W., & Grunze, H. (2007). The poor prognosis of childhood-onset bipolar disorder. The Journal of Pediatrics, 150, 485–490. https://doi.org/10.1016/j.jpeds.2006.10.070.
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.
Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003b). Bipolar disorders during adolescence. Acta Psychiatrica Scandinavica, 108, 47–50. https://doi.org/10.1034/j.1600-0447.108.s418.10.x.
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.
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.
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.
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.
McKay, M. M., & Bannon, Jr., W. M. (2004). Engaging families in child mental health services. Child and Adolescent Psychiatric Clinics of North America, 13, 905–921. https://doi.org/10.1016/j.chc.2004.04.001.
McKay, M. M., Harrison, M. E., Gonzales, J., Kim, L., & Quintana, E. (2002). Multiple-family groups for urban children with conduct difficulties and their families. Psychiatric Services, 53, 1467–1468. https://doi.org/10.1176/appi.ps.53.11.1467.
McLeod, J. D., Uemura, R., & Rohrman, S. (2012). Adolescent mental health, behavior problems, and academic achievement. Journal of Health and Social Behavior, 53, 482–497. https://doi.org/10.1177/0022146512462888.
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.
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.
Miklowitz, D. J., Biuckians, A., & Richards, J. A. (2006). Early-onset bipolar disorder: A family treatment perspective. Development and Psychopathology, 18, 1247–1265. https://doi.org/10.1017/S0954579406060603.
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.
Morrissey-Kane, E., & Prinz, R. J. (1999). Engagement in child and adolescent treatment: The role of parental cognitions and attributions. Clinical Child and Family Psychology Review, 2, 183–198. https://doi.org/10.1023/A:1021807106455.
Nadkarni, R. B., & Fristad, M. A. (2012). Stress and support for parents of youth with bipolar disorder. The Israel Journal of Psychiatry and Related Sciences, 49, 104–110.
Olson, D. (2011). FACES IV and the circumplex model: Validation study. Journal of Marital and Family Therapy, 37, 64–80. https://doi.org/10.1111/j.1752-0606.2009.00175.x.
Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A global public-health challenge. The Lancet, 369, 1302–1313. https://doi.org/10.1016/S0140-6736(07)60368-7.
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.
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.
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.
Perrino, T., Coatsworth, J. D., Briones, E., Pantin, H., & Szapocznik, J. (2001). Initial engagement in parent-centered preventive interventions: A family systems perspective. Journal of Primary Prevention, 22, 21–44. https://doi.org/10.1023/A:1011036130341.
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.
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.
Prinz, R. J., & Miller, G. E. (1994). Family-based treatment for childhood antisocial behavior: Experimental influences on dropout and engagement. Journal of Consulting and Clinical Psychology, 62, 645.https://doi.org/10.1037/0022-006X.62.3.645.
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.
Sirles, E. A. (1990). Dropout from intake, diagnostics, and treatment. Community Mental Health Journal, 26, 345–360. https://doi.org/10.1007/BF00752725.
Staudt, M. (2007). Treatment engagement with caregivers of at-risk children: Gaps in research and conceptualization. Journal of Child and Family Studies, 16, 183–196. https://doi.org/10.1007/s10826-006-9077-2.
Sullivan, A. E., Judd, C. M., Axelson, D. A., & Miklowitz, D. J. (2012). Family functioning and the course of adolescent bipolar disorder. Behavior Therapy, 43, 837–847. https://doi.org/10.1016/j.beth.2012.04.005.
Sullivan, A. E., & Miklowitz, D. J. (2010). Family functioning among adolescents with bipolar disorder. Journal of Family Psychology, 24, 60.https://doi.org/10.1037/a0018183.
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.
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.
Washburn, J. J., West, A. E., & Heil, J. A. (2011). Treatment of pediatric bipolar disorder: A review. Minerva Psichiatrica, 52, 21.
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.
Weinstein, S. M., Van Meter, A., Katz, A. C., Peters, A. T., & West, A. E. (2015). Cognitive and family correlates of current suicidal ideation in children with bipolar disorder. Journal of Affective Disorders, 173, 15–21. https://doi.org/10.1016/j.jad.2014.10.058.
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.
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.
West, A. E., Celio, C. I., Henry, D. B., & Pavuluri, M. N. (2011). Child Mania Rating Scale-Parent Version: A valid measure of symptom change due to pharmacotherapy. Journal of Affective Disorders, 128, 112–119. https://doi.org/10.1016/j.jad.2010.06.013.
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.
West, A. E., & Weinstein, S. M. (2011). A family-based psychosocial treatment model. The Israel Journal of Psychiatry and Related Sciences, 49, 86–93.
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.
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.
Funding
This study was funded by the National Institute of Mental Health (K23 MH079935) and the American Foundation for Suicide Prevention (YIG1-140-11).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
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.
Ethical Approval
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
Informed consent was obtained from all individual participants included in the study.
Rights and permissions
About this article
Cite this article
Isaia, A.R., Weinstein, S.M., Shankman, S.A. et al. Predictors of Dropout in Family-Based Psychosocial Treatment for Pediatric Bipolar Disorder: An Exploratory Study. J Child Fam Stud 27, 2901–2917 (2018). https://doi.org/10.1007/s10826-018-1126-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10826-018-1126-0