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Family-Focused Treatment for Adolescents (FFT-A)

Scientific Rating:
2
Supported by Research Evidence
See scale of 1-5
Child Welfare Relevance Level:
Medium

See descriptions of 3 levels

Brief Description

The information in this program outline is provided by the program representative and edited by the CEBC staff. The Family-Focused Treatment for Adolescents (FFT-A) program has been rated by the CEBC in the area of: Bipolar Disorder Treatment (Child & Adolescent).

  • Types of Maltreatment: Does not target any specific kind of maltreatment
  • Target Population: Adolescents with bipolar disorder and their family members.

FFT-A is a psychosocial treatment for youth with bipolar disorder, consisting of family psychoeducation, communication enhancement training, and problem-solving skills training. It is given alongside of medications in the period just after an episode of bipolar disorder. The clients are the adolescent, mother/father, and where possible, siblings and extended relatives.

Essential Components

The essential components of Family-Focused Treatment for Adolescents (FFT-A) include:

  • Psychoeducation: Providing information about bipolar disorder, what causes it and what happens to people over time; why medications are important; how to recognize the early signs of a recurrence, and how to develop early intervention plans to stave off relapse.
  • Communication Enhancement Training: Teaching family members skills such as active listening, offering positive feedback, making positive requests for change, and delivering constructive criticism.
  • Problem-Solving Skills Training: Teaching youth and families the process of defining a specific problem, generating solutions, evaluating the pros and cons of each possible solution, choosing a solution, and developing an implementation plan.

Child Component

Family-Focused Treatment for Adolescents (FFT-A) was designed with a child component that addresses the following presenting problems and symptoms:

  • Having a diagnosis of bipolar disorder.

Age range: 9 – 17

Developmental Delays:

This program was not developed for children with developmental delays, and has not been tested for children with developmental delays.

Parent / Caregiver Component

Family-Focused Treatment for Adolescents (FFT-A) was designed with a parent/caregiver component that addresses the following presenting problems and symptoms:

  • Having a child diagnosed with bipolar disorder.

Group Format

Family-Focused Treatment for Adolescents (FFT-A) was not designed to be conducted in a group setting, and has not been tested for use in a group setting.

Delivery Setting

This program is typically conducted in a(n):

  • Outpatient Clinic

Homework

Family-Focused Treatment for Adolescents (FFT-A) includes a homework component:

Families have homework each week, such as completing a mood chart, practicing communication or problem-solving skills, and practicing identifying early warning signs.

Languages

Family-Focused Treatment for Adolescents (FFT-A) does not have materials available in a language other than English.

Resources Needed to Run Program

The typical resources for implementing the program are:

  • One family therapist
  • A room large enough to see a family of 5-6
  • Audio recording capability

Minimum Provider Qualifications

Some experience in working with bipolar patients; an understanding of the disorder and how it is treated (much of this is in the treatment manual); 1-2 years of counseling or therapy experience; and family therapy experience preferred but not a requirement.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
Training is obtained:

Regional or by contract with individual settings.

Number of days/hours:

8 hours.

Additional Resources:

There currently are additional qualified resources for training:

  • Elizabeth George, PhD, Co-trainer
    phone: 303-207-1161
  • Dawn Taylor, PhD, Co-trainer
    phone: 303-473-4435

Implementation Information

Since Family-Focused Treatment for Adolescents (FFT-A) is highly rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

Show implementation information...

Pre-Implementation Assessments

There are no pre-implementation assessments to measure organizational or individual provider readiness.

Implementation Tools — for the program (e.g., implementation guides or manuals)

There is a treatment manual available for FFT-A: Bipolar Disorder: A Family-Focused Treatment Approach.

Fidelity Measures

There is a fidelity measure available for FFT-A: Therapist Competency and Adherence Scale (TCAS) for Family-Focused Treatment. For information on it, please contact Dr. David Miklowitz via email at DMiklowitz@mednet.ucla.edu.

Relevant Published, Peer-Reviewed Research

This program is rated a "2 - Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one rigorous randomized controlled trial with a sustained effect of at least 6 months. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

Show relevant research...

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(Suppl 1), 113-128.

Type of Study: Within-group pre-test/post-test open trial
Number of Participants: 20

Population:

  • Age range — Unspecified; mean 14.8
  • Race/Ethnicity — 2 “ethnic minority”, rest unspecified
  • Gender — 11 boys, 9 girls
  • Status — 16 adolescents met Diagnostic and Statistical Manual of Mental Disorders – Text Revision (DSM-IV-TR) criteria for bipolar I disorder, with an acute illness episode within the last 3 months (4 with a DSM-IV manic episode, 4 with a depressive episode, 5 with a mixed episode, and 3 with alternating periods of mania and depression). One adolescent met criteria for bipolar II disorder with a depressed index episode, alternating with periods of hypomania. Three adolescents met criteria for bipolar disorder not otherwise specified (BP-NOS).

Location / Institution: University of Colorado, CO; University of Pittsburgh, PA

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Adolescents and their families participated in a 9-month open trial of family-focused psychoeducational treatment for bipolar adolescents (FFT-A) plus pharmacotherapy. Families who desired further treatment after 9 months were offered maintenance sessions every 3 months for the next 15 months (up to 24 months). Of the 20 families, 10 requested and received extra sessions during a second study year. Measures included the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL), which was used to determine diagnoses, as well as the Camberwell Family Interview and Coding System, which assessed levels of expressed emotion in each parent, including the number of critical comments, levels of hostility, and levels of emotional overinvolvement. Additionally, parents completed the Child Behavior Checklist (CBCL) which measures internalizing and externalizing symptoms in children, at every follow-up visit. Results showed that the combination of FFT-A and mood-stabilizing medications was associated with improvements in depression symptoms, mania symptoms, and behavior problems over 1 year. Limitations include the small sample size, lack of control group, and lack of post-treatment follow-up data.

Length of post-intervention follow-up: None.

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(9), 1053-1061.

Type of Study: Randomized controlled trial
Number of Participants: 58

Population:

  • Age range — 12–17 years
  • Race/Ethnicity — 3 Hispanic, 3 Biracial, 1 Asian/Pacific Islander, 1 Native American, 1 African American, remainder unspecified
  • Gender — 33 Female, 25 Male
  • Status — Participants were adolescents with Bipolar Spectrum Disorder (either BPD I, II, or not otherwise specified) with a minimum 1- to 2-week period of illness in the prior 3 months. Patients at the University of Colorado site were recruited through direct referral by community psychiatrists or the inpatient units of Children’s Hospital of Denver; patients at the University of Pittsburg School of Medicine site were existing patients or new referrals to the Child and Adolescent Bipolar Services Clinic.

Location / Institution: University of Colorado, CO; University of Pittsburgh School of Medicine, PA

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Patients were randomly assigned to Family-Focused Treatment for Adolescents (FFT-A) and protocol pharmacotherapy (n = 30) or enhanced care (EC) and protocol pharmacotherapy (n = 28). The FFT-A consisted of 21 sessions of psychoeducation, communication training, and problem-solving skills training in a 9-month period. The EC consisted of 3 family sessions focused on relapse prevention. Adolescents and family members in FFT-A and EC had the option of receiving additional family or individual crisis sessions as needed throughout the 2-year study. An independent evaluator interviewed the patients and at least 1 parent at study entry (covering the prior 3 months), every 3 months in year 1, and every 6 months in year 2. Measures included the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL), which was used to determine diagnoses; the mood sections of the K-SADS-PL were replaced with the K-SADS Depression and Mania Rating Scales (DRS and MRS). Also, the Child’s Global Assessment Scale (C-GAS) was used to assess overall functioning for the prior 2 weeks, the most severe past episode, and the highest level in the past year. Results showed that participants in FFT-A recovered from their baseline depressive symptoms faster than patients in EC. Also, patients in FFT-A had greater overall reductions in mood severity scores (including mania, hypomania, and depression symptoms) than patients in EC over 2 years. Additionally, those treated with FFT-A spent fewer weeks in depressive episodes and had a more favorable trajectory of depression symptoms for 2 years, than those treated with EC. Limitations of the study include the small sample size, variability in treatment length among participants, and the minimal level of racial/ethnic diversity within the sample.

Length of post-intervention follow-up: 15 months for FFT-A (9 months treatment during 24-month study). 23 months for EC (3 weeks of control treatment during 24-month study).

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 and Adolescent Psychiatry, 48, 643-651.

Type of Study: Randomized controlled trial (same sample as Miklowitz, D. J., Axelson, D. A., Birmaher, B., et al., 2008, summarized above.)
Number of Participants: 52 (6 participants out of original sample of 58 had missing EE data)

Population:

  • Age range — 12 years, 0 months – 17 years, 11 months
  • Race/Ethnicity — 2% Hispanic, 6% Biracial, 2% Asian/Pacific Islander, 2% Native American, 2% African American, remainder unspecified
  • Gender — 63% Female, 37% Male
  • Status — Participants were adolescents with Bipolar Spectrum Disorder (either BPD I, II, or not otherwise specified) with a minimum 1- to 2-week period of illness in the prior 3 months. Patients at the University of Colorado site were recruited through direct referral by community psychiatrists or the inpatient units of Children’s Hospital of Denver; patients at the University of Pittsburg School of Medicine site were existing patients or new referrals to the Child and Adolescent Bipolar Services Clinic.

Location / Institution: University of Colorado, CO; University of Pittsburgh School of Medicine, PA

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Same sample as Miklowitz, D. J., Axelson, D. A., Birmaher, B., et al., 2008, summarized above. This study examined the moderating effects of parental expressed emotion (EE) on the 2-year symptomatic outcomes of adolescent BPD patients assigned to Family-Focused Treatment for Adolescents (FFT-A) or a brief psychoeducational treatment (enhanced care [EC]). Patients were randomly assigned to FFT-A and protocol pharmacotherapy (n = 30) or enhanced care (EC) and protocol pharmacotherapy (n = 28). The FFT-A consisted of 21 sessions in 9 months of psychoeducation, communication training, and problem-solving skills training. The EC consisted of 3 family sessions focused on relapse prevention. Adolescents and family members in FFT-A and EC had the option of receiving additional family or individual crisis sessions as needed throughout the 2-year study. Measures included the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL), which was used to determine diagnoses; the mood sections of the K-SADS-PL were replaced with the K-SADS Depression and Mania Rating Scales (DRS and MRS). Also, the Child’s Global Assessment Scale (C-GAS) was used to assess overall functioning for the prior 2 weeks, the most severe past episode, and the highest level in the past year. To determine level of EE within families, the Camberwell Family Interview for EE was used to interview parents and assess the number of critical comments, hostility, and emotional overinvolvement. Parents also filled out the Family Adaptability and Cohesion Scale-II (FACES-II), which assesses family cohesion and adaptability on 5-point scales of frequency. Results showed that parents rated high in EE described their families as lower in cohesion and adaptability than parents rated low in EE. Adolescents in high-EE families showed greater reductions in depressive and manic symptoms in FFT-A than in EC, suggesting that parental EE moderates the impact of family intervention on the symptomatic trajectory of adolescent BPD.

Length of post-intervention follow-up: 15 months for FFT-A (9 months treatment during 24 month study). 23 months for EC (3 weeks of control treatment during 24 month study).

References

Miklowitz, D. J. (2008). Bipolar disorder: A Family-Focused Treatment approach (2nd ed.). New York, NY: Guilford Press.

Miklowitz, D. J. (2002). The bipolar disorder survival guide. New York: Guilford Press.

Miklowitz, D. J., & George, E. L. (2008). The bipolar teen: What you can do to help your teen and your family. New York: Guilford Publications.

Contact Information

Name: David J. Miklowitz, PhD
Agency/Affiliation: University of California-Los Angeles
Website: www.semel.ucla.edu/champ
Email:
Phone: (310) 267-2659
Fax: (310) 206-4446

Date Reviewed: September 2010