Family-Focused Treatment for Adolescents (FFT-A)

About This Program

Target Population: Adolescents with bipolar disorder and their family members

For children/adolescents ages: 9 – 17

For parents/caregivers of children ages: 9 – 17

Program Overview

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.

Program Goals

The overall goals of Family-Focused Treatment for Adolescents (FFT-A) are:

  • Encourage a greater understanding of the adolescent's current symptoms and how they reflect the syndrome of bipolar disorder
  • Assist the adolescent and parents in understanding his/her vulnerability to future relapses and develop relapse prevention plans
  • Encourage a greater acceptance of the need for psychotropic medications to maintain mood stability
  • Help the adolescent and family distinguish mood symptoms from ordinary development or personality/temperament
  • Help the adolescent and family to recognize and minimize the effects of stressors that may elicit symptoms
  • Enhance the functioning of the family unit in terms of its communication and problem-solving skills

Logic Model

The program representative did not provide information about a Logic Model for Family-Focused Treatment for Adolescents (FFT-A).

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.

Program Delivery

Child/Adolescent Services

Family-Focused Treatment for Adolescents (FFT-A) directly provides services to children/adolescents and addresses the following:

  • Having a diagnosis of bipolar disorder

Parent/Caregiver Services

Family-Focused Treatment for Adolescents (FFT-A) directly provides services to parents/caregivers and addresses the following:

  • Having a child diagnosed with bipolar disorder

Recommended Intensity:

21 one-hour sessions: 12 weekly, 6 biweekly, and 3 monthly

Recommended Duration:

9 months

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.

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

Manuals and Training

Prerequisite/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.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

The manual can be downloaded at www.semel.ucla.edu/champ/downloads-clinicians

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

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

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Family-Focused Treatment for Adolescents (FFT-A).

Formal Support for Implementation

There is no formal support available for implementation of Family-Focused Treatment for Adolescents (FFT-A).

Fidelity Measures

There are fidelity measures for Family-Focused Treatment for Adolescents (FFT-A) as listed below:

There is a 13-item Therapy Competence and Adherence Scale for FFT-A. This scale is rated by supervisors who listen to session tapes.

Implementation Guides or Manuals

There are implementation guides or manuals for Family-Focused Treatment for Adolescents (FFT-A) as listed below:

The FFT-A manual is available for download from https://www.semel.ucla.edu/sites/default/files/group_news/APPENDIX%20B%20FAMILY%20FOCUSED%20TREATMENT%20MANUAL_0.pdf or able to be purchased in book form: Miklowitz, D. J. (2010). Bipolar disorder: A Family-Focused Treatment approach, 2nd Ed. New York: Guilford.

Research on How to Implement the Program

Research has not been conducted on how to implement Family-Focused Treatment for Adolescents (FFT-A).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

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. https://doi.org/10.1001/archpsyc.65.9.1053

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

Population:

  • Age — 12–17 years
  • Race/Ethnicity — 3 Hispanic, 3 Biracial, 1 Asian/Pacific Islander, 1 Native American, 1 African American, and remainder unspecified
  • Gender — 57% Female and 43% Male
  • Status — Participants were adolescents with bipolar disorder who were recruited through direct referral by community psychiatrists or the inpatient units of Children’s Hospital of Denver.

Location/Institution: University of Colorado & University of Pittsburgh School of Medicine

Summary: (To include basic study design, measures, results, and notable limitations)
The study evaluated the efficacy of Family-Focused Treatment for Adolescents (FFT-A) in a sample of adolescents with bipolar disorder. Participants were randomly assigned to a FFT-A treatment group with protocol pharmacotherapy or to a control group of enhanced care (EC) and protocol pharmacotherapy. Adolescents were assessed at intake, every 3 months during year 1 of the study, and every 6 months during year 2. Measures used included the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL), K-SADS Depression and Mania Rating Scales (DRS and MRS), and the Child’s Global Assessment Scale (C-GAS). Results indicated that participants in FFT-A recovered from 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. Limitations of the study include the small sample size, variability in treatment length among participants, and lack of ethnic diversity in the sample.

Length of postintervention follow-up: 15 months.

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. https://doi.org/10.1097/CHI.0b013e3181a0ab9d

Type of Study: Randomized controlled trial
Number of Participants: 52

Population:

  • Age — 12-17 years
  • Race/Ethnicity — 2% Hispanic, 6% Biracial, 2% Asian/Pacific Islander, 2% Native American, 2% African American, and remainder unspecified
  • Gender — 63% Female and 37% Male
  • Status — Participants were adolescents with bipolar disorder who were recruited through direct referral by community psychiatrists or the inpatient units of Children’s Hospital of Denver.

Location/Institution: University of Colorado and University of Pittsburgh School of Medicine

Summary: (To include basic study design, measures, results, and notable limitations)
Note: The study used the same sample as the Miklowitz et al. (2008) study. The study evaluated the moderating effects of parental expressed emotion on the 2-year symptomatic outcomes of adolescent bipolar disorder patients assigned to Family-Focused Treatment for Adolescents (FFT-A) or a brief psychoeducational treatment (enhanced care). Measures included the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL), K-SADS Depression and Mania Rating Scales (DRS and MRS), Child’s Global Assessment Scale (C-GAS), Camberwell Family Interview for EE, and the Family Adaptability and Cohesion Scale-II (FACES-II). Results indicated that parents rated high in parental expressed emotion described their families as lower in cohesion and adaptability than parents rated low in parental expressed emotion. Adolescents in high-parental expressed emotion families showed greater reductions in depressive and manic symptoms in FFT-A than in enhanced care, suggesting that parental expressed emotion moderates the impact of family intervention on the symptomatic trajectory of adolescent bipolar disorder.  

Length of postintervention follow-up: 15 months.

Miklowitz, D. J., Schneck, C. D., George, E. L., Taylor, D. O., Sugar, C. A., Birmaher, B., Kowatch, R. A., DelBello, M. P., & Axelson, D. A. (2014). A 2-year randomized trial of pharmacotherapy and family-focused treatment for adolescents with bipolar I and II disorders. American Journal of Psychiatry, 171(6), 658–667. https://doi.org/10.1176/appi.ajp.2014.13081130

Type of Study: Randomized controlled trial
Number of Participants: 145

Population:

  • Age — Mean=15.6 years
  • Race/Ethnicity — 17% Non-White and 9% Hispanic
  • Gender — 54% Female
  • Status — Participants were children with Bipolar I or II disorders and a DSM-IV-TR manic, hypomanic, depressive, or mixed episode in the previous 3 months.

Location/Institution: University of Colorado, the University of Pittsburgh School of Medicine, and the Cincinnati Children’s Hospital Medical Center

Summary: (To include basic study design, measures, results, and notable limitations)
This study examined whether pharmacotherapy and Family-Focused Treatment for Adolescents (FFT-A) with bipolar disorder was more effective than pharmacotherapy and brief psychoeducation (enhanced care; EC) in decreasing time to recovery from a mood episode, increasing time to recurrence, and reducing symptom severity over 2 years. Participants were randomly assigned, with family members, either to pharmacotherapy and FFT-A or to pharmacotherapy and three weekly sessions of EC. Measures included the Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL), the Therapist Competency and Adherence Scale, and the Adolescent Longitudinal Interval Follow-up Evaluation. Results indicated that the time to recovery or recurrence and proportion of weeks ill did not differ between the two treatment groups. Secondary analyses revealed that participants in FFT-A had less severe manic symptoms during year 2 than did those in enhanced care. Limitations include the high attrition rates at the later follow-up time points.

Length of postintervention follow-up: Varies (3, 6, 9, 12, 18, 24 months).

O'Donnell , L. A., Ellis, A. J., Van de Loo, M. M., Stange, J. P., Axelson, D. A., Kowatch, R. A., Schneck, C. D., & Miklowitz, D. J. (2018). Mood instability as a predictor of clinical and functional outcomes in adolescents with bipolar I and bipolar II disorder. Journal of Affective Disorders, 236, 199–206. https://doi.org/10.1016/j.jad.2018.04.021

Type of Study: Randomized controlled trial
Number of Participants: 145

Population:

  • Age — Mean=15.6 years
  • Race/Ethnicity — Not specified
  • Gender — 79 Females and 66 Males
  • Status — Participants were adolescents with bipolar disorder (BD) I or II with a mood episode.

Location/Institution: Three U.S. sites: University of Colorado, Boulder, CO; University of Pittsburgh School of Medicine, Pittsburgh, PA; the University of Cincinnati/Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

Summary: (To include basic study design, measures, results, and notable limitations)
This study used the same sample from Miklowitz et al. (2014). The purpose of this study was to examine whether mood instability (MI) among adolescents with bipolar disorder (BD) was cross-sectionally related to bipolar subtype (I vs. II) and prognostically associated with symptoms and functioning over 3 months. Participants were randomized to either Family-Focused Treatment for Adolescents (FFT-A) or enhanced care (EC, brief psychoeducation), plus good practice pharmacotherapy. Measures utilized include the Adolescent Longitudinal Interval Follow-Up Evaluation (ALIFE) and the Children’s Global Assessment Scale (CGAS). Results indicate that greater depression instability was associated with BD II, whereas greater (hypo)mania instability was associated with BD I. Baseline MI, particularly depression, predicted more instability, a higher percentage of weeks in a clinical mood state, and poorer global functioning over 3 months, even when covarying concurrent mood severity scores. Limitations include the clinical measure of symptoms used retrospective reports of clinically significant symptoms only; the sample was primarily Caucasian, from middle to upper class homes; and inability to standardize medication use or adherence.

Length of postintervention follow-up: None.

Weintra ub, M. J., Axelson, D. A., Kowatch, R. A., Schneck, C. D., & Miklowitz, D. J. (2019). Comorbid disorders as moderators of response to family interventions among adolescents with bipolar disorder. Journal of Affective Disorders, 246(1), 754–762. https://doi.org/10.1016/j.jad.2018.12.125

Type of Study: Randomized controlled trial
Number of Participants: 145

Population:

  • Age — 12–18 years, Mean=15.6 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were adolescents with bipolar I or II disorder. 

Location/Institution: University of Colorado; the University of Pittsburgh School of Medicine; and the Cincinnati Children’s Hospital Medical Center

Summary: (To include basic study design, measures, results, and notable limitations)
This study used the same sample from Miklowitz et al. (2014). The purpose of this study was to examine the effects of comorbid psychiatric conditions on patients’ symptomatic or functional responses to treatment. Adolescents were randomly assigned to Family-Focused Treatment for Adolescents (FFT-A) or a brief psychoeducational therapy (enhanced care; EC) and followed over 2 years. Participants received pharmacotherapy for the study’s duration. Measures utilized include the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), the Mania Rating Scale Psychiatric Status Rating Scale (PSR) of the Adolescent Longitudinal Interval Follow-up Evaluation (ALIFE), the ALIFE PSR depression, hypomanic, and manic scales, and the Conflict Behavior Questionnaire (CBQ). Results indicate that comorbid anxiety was associated with a greater proportion of weeks with depressive symptoms, more severe (hypo)manic symptoms during follow-up, and greater family conflict over the 2-year study. Comorbid ADHD was associated with a greater proportion of weeks with (hypo)manic symptoms, more severe (hypo)manic symptoms, and greater family conflict. Additionally, comorbid ADHD moderated the effects of psychosocial treatments on (hypo)manic symptoms and family functioning. Comorbid DBDs were consistently associated with more severe depressive symptoms and greater family conflict throughout the study. Limitations include randomization to treatments was not stratified on comorbid disorders, and the course of anxiety, attentional, and disruptive behavior symptoms were not examined.

Length of postintervention follow-up: 3, 9, and 15 months.

Weintraub , M. J., Schneck, C. D., Axelson, D. A., Birmaher, B., Kowatch, R. A., & Miklowitz, D. J. (2020). Classifying mood symptom trajectories in adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 59(3), 381–390. https://doi.org/10.1016/j.jaac.2019.04.028

Type of Study: Randomized controlled trial
Number of Participants: 144

Population:

  • Age — 12–18 years
  • Race/Ethnicity — 17% Non-White and 8% Hispanic
  • Gender — 55% Female
  • Status — Participants included adolescents with a DSM-IV-TR diagnosis of bipolar I or II disorder. 

Location/Institution: Three university centers: University of Colorado, Boulder; the University of Pittsburgh School of Medicine; and the Cincinnati Children’s Hospital Medical Center

Summary: (To include basic study design, measures, results, and notable limitations)
This study used the same sample from Miklowitz et al. (2014). The purpose of this study was to evaluate whether adolescents with bipolar spectrum disorders followed 1 of 4 distinct mood trajectories. Participants were randomly assigned to one of 2 psychosocial family treatments during the first 9 months of the study, and pharmacotherapy was provided throughout the 2 years. Measures utilized include the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS), the Adolescent Longitudinal Interval Follow-Up Evaluation (ALIFE), the Hollingshead Scale, the Family History Screen, the Five-Minute Speech Sample, and the Kiddo-KINDLR Questionnaire (KINDL). Results indicate four mood trajectories: predominantly euthymic, ill with significantly improving course, moderately euthymic, and ill with moderately improving course. Adolescents in these classes were euthymic. Psychosocial treatment condition and baseline medication exposure were not associated with trajectories. However, youth with more severe baseline depressive symptoms, suicidality, lower quality of life scores, and minority race/ ethnicity had more symptomatic courses of illness over time. Limitations include the sample size, especially for small subgroup comparisons; limited the ability to detect differences; the generalizability of the findings pertain mostly to older adolescents with bipolar disorder; and recall and hindsight bias.

Length of postintervention follow-up: 9 and 15 months.

Additional References

Miklowitz, D. J. (2010). Bipolar disorder: A Family-Focused Treatment approach (2nd ed.). New York: Guilford Press.

Miklowitz, D. J. (2011). The bipolar disorder survival guide (2nd ed.). 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

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 Research Evidence Last Reviewed by CEBC: January 2021

Date Program Content Last Reviewed by Program Staff: April 2014

Date Program Originally Loaded onto CEBC: September 2010