Mania and ADHD: comorbidity or confusion

Proton magnetic resonance spectroscopy in youth with severe mood dysregulation

Increasing numbers of youth are presenting for psychiatric evaluation with markedly irritable mood plus "hyperarousal" symptoms. Diagnostically homeless in current nosology, the syndrome (as well as its underlying neurobiology) is little understood. To address this problem, we conducted an exploratory proton magnetic resonance spectroscopy (MRS) study in a large sample of youth with chronic, functionally disabling irritability accompanied by hyperarousal, a clinical syndrome known as "severe mood dysregulation" (SMD), which may represent a broad phenotype of pediatric bipolar disorder. Medication-free SMD youth (N=36) and controls (N=48) underwent 1.5 Tesla MRS in four regions of interest. The following three neurometabolites, relative to creatine (Cr), were quantified with LCModel Software: (a) myo-inositol (mI), a marker of intra-cellular second messengers linked to the neurobiology of bipolar disorder; (b) glutamate/glutamine (GLX), a marker of the major excitatory neurotransmitter glutamate; and (c) N-acetyl aspartate (NAA), a marker of neuronal energetics. SMD subjects had significantly lower temporal mI/Cr versus controls. However, this difference did not survive correction for multiple comparisons. Given studies implicating mI in lithium's action in BD adults and youth, further work is necessary to determine potential therapeutic implications of our present finding and how SMD youth differ pathophysiologically from those with strictly defined BD.

Processing of differentially valued rewards and punishments in youths with bipolar disorder or severe mood dysregulation

BACKGROUND

Youths with chronic irritability and hyperarousal (i.e., severe mood dysregulation, SMD) have reward- and punishment-processing deficits distinct from those exhibited by children with episodic symptoms of mania (i.e., narrow-phenotype bipolar disorder, BD). Additionally, youths with SMD, like those with psychopathy, have prominent reactive aggression. Therefore, we hypothesized that SMD, but not BD, youths would be impaired on a decision-making task that has identified reward- and punishment-processing deficits in individuals with psychopathy.

METHODS

A decision-making task was used in which BD (n = 23), SMD (n = 37), and control subjects (n = 31) were asked to choose between two images associated with different levels of reward or punishment.

RESULTS

No between-group differences in task performance were found.

CONCLUSION

These results suggest that BD, SMD, and normal youths do not differ in their ability to select between rewards and punishments of different value. Effect-size analyses suggest that this finding is not secondary to a type II error. Unlike individuals with psychopathy, neither SMD subjects nor those with BD differ from controls in their ability to select between differentially valued rewards and punishments.

Prepubertal mania: diagnostic differences between US and UK clinicians

OBJECTIVE

To test the hypothesis that US clinicians diagnose prepubertal mania more commonly than UK clinicians.

METHODS

Five vignettes were presented to 73 UK clinicians and 85 US clinicians. Four cases represented complex scenarios where the diagnosis of mania was thought to be controversial, and one case was a 'classical' case of mania in an older child where it was thought there would be good agreement. Clinicians were asked to determine symptoms of mania, and their preferred diagnoses.

RESULTS

As predicted, overall there were significantly more diagnoses of mania in the US than the UK (P < or = 0.0001). US clinicians were significantly more likely to diagnose mania in three of the four complex cases, and there was good agreement in the case of classical mania. In addition, UK clinicians were significantly more likely to diagnose pervasive developmental disorders and adjustment disorders, whereas obsessive compulsive disorder was more commonly diagnosed in the US.

CONCLUSION

There may be differences in how clinicians in the US and UK interpret mania-like symptoms in younger children, which may have implications for diagnosis and management.

Initiation of stimulant and antidepressant medication and clinical presentation in juvenile bipolar I disorder

OBJECTIVES

The primary purpose of this study was to examine the extent to which the initiation of stimulant and antidepressant medication was associated with the subsequent onset of juvenile bipolar I disorder (BP I). Another aim was to investigate differences in clinical presentation between youths prescribed stimulant or antidepressant medication before and after the onset of juvenile BP I disorder.

METHODS

Youths between the ages of 5 and 17 years meeting full, unmodified DSM-IV diagnostic symptom criteria for BP were included in this study. Data regarding the age of onset of BP I, psychiatric comorbidities, and current symptoms of mania and depression were obtained. Medication history was recorded as part of the assessment interview with parents and youths.

RESULTS

Of the 245 youths with BP I, 65% (n = 160) were treated with stimulant medication; 32% (56/173) were treated after the onset of BP I, and 19% (32/173) were treated before the onset of BP I. Forty-six percent (113/245) were treated with antidepressant medication; 33% (67/206) were treated after the onset of BP I, and 3% (7/206) were treated before the onset of BP I. Patients who were treated with stimulants after the onset of BP I were significantly more likely to be younger (p < 0.0001). Patients who were treated with antidepressants before the onset of BP I were significantly more likely to be older and to have lower levels of mania on the Young Mania Rating Scale at assessment (p < 0.01).

CONCLUSIONS

Data from this retrospective case series do not support the association between initial stimulant or antidepressant use and the onset of BP I or presenting symptoms of depression or manic symptoms.

Retrospective parent report of psychiatric histories: do checklists reveal specific prodromal indicators for postpubertal-onset pediatric bipolar disorder?

OBJECTIVES

This study retrospectively investigated the relationship between prodromal symptoms described in the literature for pediatric bipolar disorder (BD) and the diagnosis of BD by comparing adolescents with BD to those in control and attention-deficit hyperactivity disorder (ADHD) groups.

METHODS

Semi-structured interviews [Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version (K-SADS-PL) and Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)] and checklists (Conners' Rating Scales and Child Behavior Checklist) identified participants (13-17 years) as either normal controls (NC; n = 28), ADHD (n = 29) or BD (n = 25). Bipolar disorder included BD I, BD II and BD not otherwise specified (NOS). Parents completed a widely used but unvalidated symptom checklist published by Papolos and Papolos (The Bipolar Child: the Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder) assessing across three developmental periods (preschool, latency, adolescence) for the presence/absence of psychiatric symptoms, many of which have been described in the literature as prodromal to the emergence of manic symptoms.

RESULTS

While both clinical groups had more psychiatric symptoms than the NC group, more problems were reported in the ADHD group, most of which were symptoms seen as cardinal features of ADHD (e.g., being easily distracted, interrupting, having trouble concentrating). Differences were present by the latency period. Depressed mood was higher in the BD group during latency, and elated mood and fire-setting were higher in the BD group during adolescence. Results were more similar when comparing adolescents with BD only versus those with both ADHD and BD. Frequency of symptoms was comparable regardless of whether or not there was a family history of BD. Frequency of symptoms was also similar across the BD subtypes.

CONCLUSIONS

Using retrospective parent report, a cluster of prodromal psychiatric symptoms specific to BD was not identified, which both questions the utility of a widely used yet unvalidated clinical scale and encourages caution when interpreting information collected via retrospective checklists. Although these data suggest that the presence of prodromal non-specific psychiatric symptoms flags a more global risk for psychopathology, significant limitations exist when using retrospective report and, as such, further prospective research is required to investigate the progression of psychiatric symptoms across childhood disorders.

Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis

OBJECTIVE

To find, review, and critically evaluate evidence pertaining to the phenomenology of pediatric bipolar disorder and its validity as a diagnosis.

METHODS

The present qualitative review summarizes and synthesizes available evidence about the phenomenology of bipolar disorder (BD) in youths, including description of the diagnostic sensitivity and specificity of symptoms, clarification about rates of cycling and mixed states, and discussion about chronic versus episodic presentations of mood dysregulation. The validity of the diagnosis of BD in youths is also evaluated based on traditional criteria including associated demographic characteristics, family environmental features, genetic bases, longitudinal studies of youths at risk of developing BD as well as youths already manifesting symptoms on the bipolar spectrum, treatment studies and pharmacologic dissection, neurobiological findings (including morphological and functional data), and other related laboratory findings. Additional sections review impairment and quality of life, personality and temperamental correlates, the clinical utility of a bipolar diagnosis in youths, and the dimensional versus categorical distinction as it applies to mood disorder in youths.

RESULTS

A schema for diagnosis of BD in youths is developed, including a review of different operational definitions of 'bipolar not otherwise specified.' Principal areas of disagreement appear to include the relative role of elated versus irritable mood in assessment, and also the limits of the extent of the bipolar spectrum--when do definitions become so broad that they are no longer describing 'bipolar' cases?

CONCLUSIONS

In spite of these areas of disagreement, considerable evidence has amassed supporting the validity of the bipolar diagnosis in children and adolescents.

Methylphenidate in the treatment of children and adolescents with bipolar disorder and attention-deficit/hyperactivity disorder

OBJECTIVE

To examine the short-term efficacy of methylphenidate in the treatment of youths with bipolar disorder (BD) and comorbid attention deficit/hyperactivity disorder (ADHD).

METHOD

A 4-week double-blind, placebo-controlled trial in youths ages 5 to 17 years was conducted. Subjects met DSM-IV criteria for bipolar disorder and ADHD, were currently receiving a stable dose of at least one thymoleptic, and while euthymic continued to have clinically significant symptoms of ADHD. Patients received 1 week each of placebo, methylphenidate 5 mg twice daily, methylphenidate 10 mg twice daily, and methylphenidate 15 mg twice daily using a crossover design. Subjects were randomly assigned to receive one of six possible dosing orders. At study's end, and before the blind being broken, a "best dose week" for each subject was determined. The primary outcome measure was the total score on the parent-completed ADHD Rating Scale-IV.

RESULTS

Sixteen patients, with a mean age of 10.43 (SD 3.14) years completed the trial. Lower scores during best dose treatment compared to the week of placebo treatment were found on the ADHD Rating Scale-IV (p < .05), suggesting a therapeutic benefit. A large effect size (Cohen's d = 0.90) was found for methylphenidate. Treatment was generally well tolerated.

CONCLUSIONS

Euthymic youths with bipolar disorder and ADHD may benefit from short-term concomitant treatment with methylphenidate.

Psychiatric comorbidity in ADHD symptom subtypes in clinic and community adults

OBJECTIVE

To compare psychiatric comorbidity between the three symptom subtypes of Attention-Deficit/Hyperactivity Disorder (ADHD), Inattentive (I), Hyperactive-Impulsive (H), and Combined (C), in adults.

METHOD

A clinic sample (N = 487) and a nonreferred community sample (N = 900) completed a DSM-IV-referenced rating scale and a questionnaire (social, educational, occupational, and treatment variables). Participants were assigned to one of four groups: ADHD:I, ADHD:H, ADHD:C, and NONE.

RESULTS

All three ADHD symptom groups reported more severe comorbid symptoms than the NONE group; the ADHD:C and NONE groups were the most and least severe, respectively; and there were clear differences between the ADHD:I and ADHD:H groups. The pattern of group differences was similar in both samples.

CONCLUSION

ADHD symptom subtypes in adults are associated with distinct clinical correlates. The diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations.

Specificity of facial expression labeling deficits in childhood psychopathology

BACKGROUND

We examined whether face-emotion labeling deficits are illness-specific or an epiphenomenon of generalized impairment in pediatric psychiatric disorders involving mood and behavioral dysregulation.

METHOD

Two hundred fifty-two youths (7-18 years old) completed child and adult facial expression recognition subtests from the Diagnostic Analysis of Nonverbal Accuracy (DANVA) instrument. Forty-two participants had bipolar disorder (BD), 39 had severe mood dysregulation (SMD; i.e., chronic irritability, hyperarousal without manic episodes), 44 had anxiety and/or major depressive disorders (ANX/MDD), 35 had attention-deficit/hyperactivity and/or conduct disorder (ADHD/CD), and 92 were controls. Dependent measures were number of errors labeling happy, angry, sad, or fearful emotions.

RESULTS

BD and SMD patients made more errors than ANX/MDD, ADHD/CD, or controls when labeling adult or child emotional expressions. BD and SMD patients did not differ in their emotion-labeling deficits.

CONCLUSIONS

Face-emotion labeling deficits differentiate BD and SMD patients from patients with ANX/MDD or ADHD/CD and controls. The extent to which such deficits cause vs. result from emotional dysregulation requires further study.

Increased rates of bipolar disorder diagnoses among U.S. child, adolescent, and adult inpatients, 1996-2004

BACKGROUND

Volatile, aggressive behavior is the chief complaint that brings children to inpatient psychiatric care. These difficulties are increasingly conceptualized as bipolar disorder (BD). The impact of doing so on clinical diagnoses in clinical care is uncertain.

METHODS

We extracted records from the annual National Hospital Discharge Survey (NHDS) for which a psychiatric diagnosis was primary and examined trends in the rates of hospitalization for BD.

RESULTS

Population-adjusted rates of hospital discharges of children with a primary diagnosis of BD increased linearly over survey years. The rate in 1996 was 1.3 per 10,000 U.S. children and climbed to 7.3 per 10,000 U.S. children in 2004. Bipolar disorder related discharges also increased fourfold among adolescents. Adults showed a more modest, though still marked, rise of 56%. Bipolar disorder related hospitalization was more prevalent among female adolescents and adults, while male children had larger risk than female children. Children's BD diagnoses tended not to specify a prevailing mood state, while depression and psychotic features were the most common codes for adults. Black individuals, especially men, had lower rates of BD diagnoses in early survey years, but more recently their rate of BD related hospitalizations has exceeded other NHDS race groups.

CONCLUSIONS

Higher rates of inpatient admissions among youth associated with BD may reflect greater appreciation of the importance of affective dysregulation in this patient group or "upcoding" to putatively more severe conditions for reimbursement or administrative reasons. Further study is warranted to examine this shift's causes and implications for treatments and outcomes.

Comorbid psychopathology with autism spectrum disorder in children: an overview

Comorbidity, the co-occurrence of two or more disorders in the same person, has been a topic receiving considerable attention in the child psychopathology literature overall. Despite many publications in the ADHD, depression and other child literatures, autism spectrum disorder has not received such scrutiny. The purpose of this review will be to discuss the available evidence. We address specific variables in diagnosis and classification of comorbid symptoms, and propose potential avenues for research and practice with respect to differential diagnosis. A brief discussion of the implications for treatment is also provided.

Evidence for disruption in prefrontal cortical functions in juvenile bipolar disorder

OBJECTIVES

Systematic parsing of executive function processes is critical for the development of more specific models of neurobiological processes mediating disturbed cognition in youth with bipolar disorder (BPD).

METHODS

A sample of 33 children and adolescents with bipolar I disorder (BPD I) (mean age 12.1 +/- 3.0 years, 39% female) and 44 demographically matched healthy participants (mean age 12.9 +/- 2.8 years, 50% female) completed a neurocognitive battery including measures aimed at detection of disruption in prefrontal cortical circuitry (i.e., working memory, set shifting, and rule attainment).

RESULTS

Compared to healthy controls, BPD I children exhibited significant deficits in spatial working memory, visual sequencing and scanning, verbal fluency and abstract problem solving, particularly when a memory component was involved. In our spatial delayed response task, memory set size was parametrically varied; the performance pattern in BPD I children suggested deficits in short-term memory encoding and/or storage, rather than capacity limitations in spatial working memory. Earlier age at onset of illness and antipsychotic medication usage were associated with poorer performance on speeded information-processing tasks; however, severity of mood symptomatology and comorbidity with disruptive behavior disorders were not associated with task performance.

CONCLUSIONS

These results suggest impairment in measures of prefrontal cortical function in juvenile BPD I that are similar to those seen in the adult form of the illness, and implicate both the ventral and dorsolateral prefrontal cortex as loci of pathology in juvenile BPD. As these deficits were not associated with clinical state or comorbidity with other disorders, they may reflect trait-related impairments, a hypothesis that will be pursued further in longitudinal studies.

Emotion regulation in children and adolescents: boundaries between normalcy and bipolar disorder

Much controversy has surrounded the diagnosis of bipolar disorder (BD) in children and adolescents. However, recent work from an affective neuroscience perspective has advanced what is known about the boundaries of emotion regulation in BD compared to typically developing youth. In this article, we first briefly review the clinical issues that have contributed to this diagnostic controversy. Second, we discuss our phenotyping system, which can be used to guide neurobiological research designed to address these controversial issues. Third, we review what is known about the fundamentals of emotion regulation in human and nonhuman primate models. Fourth, we present recent data demonstrating how children and adolescents with BD differ from those without psychopathology on measures of emotion regulation. Taken as a whole, this work implicates a neural circuit encompassing the prefrontal cortex, amygdala, and striatum in the pathophysiology of pediatric BD.

Cognitive flexibility in phenotypes of pediatric bipolar disorder

OBJECTIVE

Clinicians and researchers debate whether children with chronic, nonepisodic irritability should receive the diagnosis of bipolar disorder (BD). To address this debate, we evaluated cognitive flexibility, or the ability to adapt to changing contingencies, in three groups of children: narrow-phenotype BD (NP-BD; full-duration manic episodes of elevated/expansive mood; N = 50; 13.1 +/- 2.9 years), severe mood dysregulation (SMD; chronic, nonepisodic irritability; N = 44; 12.2 +/- 2.1 years), and healthy controls (N = 43; 13.6 +/- 2.4 years). Cognitive flexibility is relevant to symptoms of BD involving dysfunctional reward systems (e.g., excessive goal-directed activity and pleasure-seeking in mania; anhedonia in depression).

METHOD

We studied simple and compound reversal stages of the intra-/extradimensional shift task and change task that involves inhibiting a prepotent response and substituting a novel response.

RESULTS

On the simple reversal, NP-BD youths were significantly more impaired than both the SMD group and controls. On the compound reversal, NP-BD and SMD youths performed worse than controls. On the change task, NP-BD youths were slower to adapt than SMD subjects.

CONCLUSIONS

Phenotypic differences in cognitive flexibility may reflect different brain/behavior mechanisms in these two patient populations.

Co-occurrence of bipolar and attention-deficit hyperactivity disorders in children

OBJECTIVES

Pediatric bipolar disorder (BPD) and attention-deficit hyperactivity disorder (ADHD) co-occur more frequently than expected by chance. In this review, we examine 4 potential explanations for the high rate of this common co-occurrence: (i) BPD symptom expression leads to overdiagnosis of ADHD in BPD youth; (ii) ADHD is a prodromal or early manifestation of pediatric-onset BPD; (iii) ADHD and associated factors (e.g., psychostimulants) lead to the onset of pediatric BPD; and (iv) ADHD and BPD share an underlying biological etiology (i.e., a common familial or genetic risk or underlying neurophysiology).

METHODS

Peer-reviewed publications of studies of children and adolescents with comorbid BPD and ADHD were reviewed.

RESULTS

There is a bidirectional overlap between BPD and ADHD in youth, with high rates of ADHD present in children with BPD (up to 85%), and elevated rates of BPD in children with ADHD (up to 22%). Phenomenologic, genetic, family, neuroimaging, and treatment studies revealed that BPD and ADHD have both common and distinct characteristics. While there are data to support all 4 explanations postulated in this paper, the literature most strongly suggests that ADHD symptoms represent a prodromal or early manifestation of pediatric-onset BPD in certain at-risk individuals. Bipolar disorder with comorbid ADHD may thus represent a developmentally specific phenotype of early-onset BPD.

CONCLUSIONS

The etiology of comorbid BPD and ADHD is likely multifactorial. Additional longitudinal and biological studies are warranted to clarify the relationships between BPD and ADHD since they may have important diagnostic and treatment implications.

Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children

BACKGROUND

Controversy concerning the diagnosis of pediatric bipolar disorder (BD) has focused attention on children with chronic irritability and hyperarousal. This syndrome has been called the "broad BD phenotype" or severe mood dysregulation (SMD). This study examines prevalence, concurrent Axis I diagnoses, and longitudinal outcome of SMD in an epidemiologic sample.

METHODS

Data were drawn from the Great Smoky Mountains Study, a longitudinal epidemiological study. Items from the Child and Adolescent Psychiatric Assessment were used to generate SMD criteria.

RESULTS

Among 1420 children, the lifetime prevalence of SMD in children ages 9-19 was 3.3%. Most (67.7%) SMD youth had an Axis I diagnosis, most commonly attention-deficit/hyperactivity disorder (26.9%), conduct disorder (25.9%), and/or oppositional defiant disorder (24.5%). In young adulthood (mean age 18.3 +/- 2.1 years), youth who met criteria for SMD in the first wave (mean age 10.6 +/- 1.4 years) were significantly more likely to be diagnosed with a depressive disorder (odds ratio 7.2, confidence interval 1.3-38.8, p = .02) than youth who never met criteria for SMD.

CONCLUSIONS

Severe mood dysregulation is relatively common in childhood and predicts risk for early adulthood depressive disorders. Research should continue to explore the course of illness in children with SMD.

The child bipolar questionnaire: a dimensional approach to screening for pediatric bipolar disorder

BACKGROUND

The Child Bipolar Questionnaire (CBQ) is a rapid screener with a Core Index subscale of symptom dimensions frequently reported in childhood-onset bipolar disorder (BD) and scoring algorithms for DSM-IV BD, with and without attention-deficit/hyperactivity disorder (ADHD), and the proposed Narrow, Broad, and Core phenotypes. This report provides preliminary data on the reliability and validity of the CBQ.

METHOD

Test-retest and inter-rater reliability of the CBQ were assessed. The ability of CBQ screening diagnoses and of the CBQ Core Index subscale to effectively predict diagnostic classification by structured interview was assessed using the K-SADS P/L.

RESULTS

Preliminary test-retest data showed excellent reliability for both the CBQ total score (r = 0.82) and the Core Index subscale (r = 0.86). Preliminary validity data was also promising. CBQ screening algorithms performed with a specificity of 97% and a sensitivity of 76% in classifying subjects with K-SADS P/L diagnosis of BD vs. no BD. The Core Index subscale had excellent agreement with K-SADS P/L diagnosis (k = 0.84) in classifying BD, ADHD-only, and no diagnosis and demonstrated 100% sensitivity and 86% specificity in classifying BD vs. no BD.

LIMITATIONS

This preliminary data is from a sample enriched with bipolar disorder cases. Further validation is needed with samples in which childhood-onset BD is rarer and diagnoses more diverse.

CONCLUSIONS

The CBQ shows potential for rapid and economically feasible identification of possible childhood-onset BD cases as defined by DSM-IV criteria as well as by alternate disease phenotypes. Further validation studies will focus on inpatient and outpatient samples with a broader range of variability.

Pediatric bipolar disease: current and future perspectives for study of its long-term course and treatment

AIM AND METHODS

Findings from recent long-term, prospective longitudinal studies of the course, outcome and naturalistic treatment of adults with bipolar illness are highlighted as background for long-term developmental study of pediatric bipolar illness.

RESULTS

Accumulating knowledge of bipolar illness in adults underscores a high risk for multiple recurrences through the lifespan, significant medical morbidity, high rates of self-harm, economic and social burden and frequent treatment resistance with residual symptoms between major episodes. At present, there is no empirical foundation to support any assumption about the long-term course or outcome of bipolar illness when it arises in childhood or adolescence, or the effects of conventional pharmacotherapies in altering its course and limiting potentially adverse outcomes. The proposed research articulates specific descriptive aims that draw on adult findings and outlines core methodological requirements for such an endeavor.

CONCLUSIONS

Innovations in the description and quantitative analysis of prospective longitudinal clinical data must now be extended to large, systematically ascertained pediatric cohorts recruited through multicenter studies if there is to be a meaningful scientific advance in our knowledge of the enduring effects of bipolar illness and the potential value of contemporary approaches to its management.

The clinical phenotypes of juvenile bipolar disorder: toward a validation of the episodic-chronic-distinction

BACKGROUND

Recent research has addressed the issue of subtyping juvenile bipolar disorder (JBD). Accordingly, we set out to find out, in a naturalistic sample of bipolar children and adolescents with mania and mixed mania, whether the most useful subtyping should be based on clinical features (elated vs. irritable) or course (episodic vs. chronic).

METHODS

We studied 136 patients, 81 male patients (59.6%) and 55 female patients (40.4%), mean age 13.5 +/- 2.9 years, meeting the DSM-IV diagnosis of bipolar disorder, assessed by a structured clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version [K-SADS-PL]).

RESULTS

Regarding course, 77 patients (56.6%) had an episodic course and 59 patients (43.4%) had a chronic course. Patients with chronic course were significantly younger, had an earlier onset of JBD, and presented a more frequent comorbidity with disruptive behavior disorders. According to the prevalent mood disturbance, 75 patients (55.1%) showed an elated and 61 patients (44.9%) showed an irritable mood. Elated mood was more frequent in patients with episodic course, whereas irritable mood was more frequent in the patients with chronic course.

CONCLUSIONS

These findings suggest that chronic versus episodic course may be a putative differential feature. Further validation of such a distinction would require prospective studies, temperament evaluation, gender and neurobiologic approaches, and differential psychopharmacologic assignment and response.

Comorbidity of attention deficit hyperactivity disorder in juvenile bipolar disorder

OBJECTIVE

There is some evidence to suggest that attention deficit hyperactivity disorder (ADHD) and juvenile bipolar disorder could be related. This is based on studies of comorbidity and some preliminary family study data. However, doubts continue to be raised about the relationship between the two disorders. This study examined the comorbidity of disruptive behavior disorders (DBD) that include ADHD, oppositional defiant disorder (ODD) and conduct disorder (CD) in juvenile bipolar disorder.

METHOD

Seventy-three subjects with onset of bipolar disorder at age 18 years or younger were evaluated using structured interviews (Missouri Assessment of Genetics Interview for Children, Structured Clinical Interview for DSM-IV Axis I disorders--Clinician Version, and Operational Criteria Checklist for Psychotic Disorders version 3.4). Information was collected from subjects as well as from their parents. Patients with comorbid DBD were compared with patients without DBD.

RESULTS

Ten subjects (14%) had one or more comorbid DBD. ADHD, CD, and ODD were present in three (4%), two (3%), and eight (11%) subjects, respectively. Those with DBD had earlier onset of bipolar disorder and spent more time ill compared to those without DBD.

CONCLUSIONS

The rates of comorbid DBD in juvenile bipolar disorder are low. The study does not support a definite relationship between ADHD and juvenile bipolar disorder. Higher rates reported previously may be due to differing methods of subject ascertainment. Samples recruited from community and general psychiatric settings may help to clarify the relationship between bipolar disorder and ADHD.

A prospective high-risk study of the association among maternal negativity, apparent frontal lobe dysfunction, and the development of bipolar disorder

In a previous paper, the authors found that impairment on the Wisconsin Card Sorting Test (WCST) in adolescence was predictive of bipolar disorder in young adulthood among offspring of mothers with bipolar illness. In the present study, the authors explore the contribution of maternal characteristics, beyond maternal mood disorder, to the prediction of offspring dysfunction on the WCST. Results showed that maternal bipolar disorder and maternal negativity were both predictive of impaired performance on the WCST during adolescence. The contribution of maternal negativity to offspring WCST impairment was not better explained by maternal personality disorder, mother's functional impairment, family loading for bipolar disorder, or offspring disruptive behavioral disturbance. Findings did not support a moderator model. However, support was found for a mediation model in which maternal negativity contributed to risk for offspring bipolar disorder through its negative association with apparent frontal lobe functioning, as measured by the WCST. Findings are discussed from the perspective of a vulnerability-stress model. In addition, the authors consider the possibility that maternal negativity and offspring impairment on the WCST may be reflective of a common heritable trait.

Comorbid ADHD is associated with altered patterns of neuronal activation in adolescents with bipolar disorder performing a simple attention task

OBJECTIVES

Bipolar disorder is increasingly recognized as a significant source of psychiatric morbidity in children and adolescents. Younger bipolar patients symptomatically differ from adults, and frequently present with comorbid disorders, particularly attention-deficit hyperactivity disorder (ADHD). The neurophysiological relationship between these two disorders, however, remains unclear. In this study we utilized functional magnetic resonance imaging (fMRI) to compare activation patterns during performance of a simple attention task between bipolar adolescents with and without ADHD.

METHODS

Eleven bipolar adolescents with comorbid ADHD and 15 bipolar adolescents without comorbidity were recruited to participate in fMRI scans. A single-digit continuous performance task alternated with a control task in a block-design paradigm. between-group comparisons were made using voxel-by-voxel analysis. Follow-up correlations were made between performance and activation.

RESULTS

Group performance did not significantly differ in percentage correct (p = 0.36) or discriminability (p = 0.11). ADHD comorbidity was associated with less activation in the ventrolateral prefrontal cortex (Brodmann 10) and anterior cingulate, and greater activation in posterior parietal cortex and middle temporal gyrus. Comorbid ADHD was associated with substantial differences in patterns of correlation between performance and voxel-by-voxel activation.

CONCLUSIONS

Our findings suggest that comorbid ADHD in bipolar adolescents is associated with activation of alternative pathways during performance of a simple attention task. The pattern of differences suggests that bipolar adolescents with comorbid ADHD demonstrate decreased activation of prefrontal regions, compared with bipolar adolescents without ADHD, and preferentially recruit portions of posterior parietal and temporal cortex.

Neurologic examination abnormalities in children with bipolar disorder or attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BPD) are frequently comorbid and overlapping diagnoses. To move beyond diagnosis toward unique pathophysiology, we evaluated both ADHD and BPD children for neurologic examination abnormalities (NEAs) in comparison with normal control (NC) children.

METHODS

We performed the Revised Physical and Neurological Examination for Soft Signs in three groups (ADHD, BPD, NC). Then, a rater blind to diagnosis evaluated their motor performance. Results were analyzed with a multiple analysis of covariance.

RESULTS

Subjects with ADHD were impaired on repetitive task reaction time. In contrast, pediatric BPD subjects, both with and without comorbid ADHD, were impaired on sequential task reaction time.

CONCLUSIONS

This differential pattern of NEAs by diagnosis suggests pathophysiologic differences between ADHD and BPD in children. Repetitive motor performance requires inhibition of nonrelevant movements; ADHD subjects' impairment in this domain supports the hypothesis that ADHD involves a core deficit of fronto-striato-basal ganglia neurocircuitry. In contrast, BPD subjects' impaired sequential motor performance is consistent with behavioral data showing impaired attentional set-shifting and reversal learning in BPD subjects. Further study, going beyond symptom description to determine pathophysiologic differences, is required to refine neuronal models of these often comorbid diagnoses.

Comorbid anxiety in phenotypes of pediatric bipolar disorder

OBJECTIVE

There has been limited research on anxiety in pediatric bipolar disorder (BPD). Adult BPD studies suggest comorbid anxiety disorders are common and impact treatment outcome. We explored the association of comorbid anxiety with two phenotypes of pediatric BPD.

METHODS

We studied two groups of children. The first group (BPD; N = 31) represents the "narrow phenotype" of pediatric BPD, meeting stringent DSM-IV criteria for mania, including duration and elevated/expansive mood. The second group (ED; N = 32) exhibited chronic, non-episodic irritability without elation or grandiosity ("broad phenotype").

RESULTS

Both samples demonstrate high prevalence of anxiety (BPD 77.4%; ED 46.9%). In the BPD sample, anxiety predates BPD onset, and those with comorbid anxiety have earlier age of onset of BPD than those without. Children with BPD plus anxiety have more hospitalizations than those without anxiety. ED subjects with and without comorbid anxiety did not differ with respect to onset of ED symptoms or number of hospitalizations.

CONCLUSIONS

Narrow and broad phenotype BPD children have high rates of comorbid anxiety, although only in the narrow phenotype group is comorbid anxiety associated with greater functional impairment BPD plus comorbid anxiety may represent a particularly severe phenotype of pediatric BPD.

Bipolar disorders in children and adolescents

In the past decade, 7 million children in the United States had a mental health problem, with higher rates of medication use, primary care visits, and specialty care visits than children without such problems. Children with bipolar disorders can present diagnostic and referral dilemmas for the primary care pediatric nurse practitioner, and frequently these children take multiple medications that interact with commonly used antibiotics, over-the-counter medications, and contraceptives. Diagnostic criteria for mania are controversial and coexisting attention deficit/hyperactivity disorder, conduct disorder, and anxiety disorders can complicate the diagnosis and treatment. The primary care pediatric nurse practitioner role includes referral, co-management, and advocacy for this vulnerable population.

Predictors of treatment nonresponse in bipolar children and adolescents with manic or mixed episodes

Even though juvenile bipolar disorder (BD) is reported to be more treatment-resistant than adult BD, predictors of nonresponse are not well studied. The aim of this study was to address this issue in a naturalistic sample of bipolar children and adolescents with manic or mixed episodes treated under the condition of routine clinical practice. This study was comprised of 40 patients (19 females and 21 males; mean age, 14.2 years; SD = 3.3; range, 7-18) with a Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) diagnosis of manic (n = 23) or mixed episodes (n = 17). The clinical characteristics of 20 patients considered to be treatment responders, according to the Clinical Global Impression-Improvement (CGI-I) scores, were compared to those of the 20 nonresponders. The effect of predictors on the probability of treatment nonresponse was analyzed using the multiple stepwise logistic regression, backward procedure. Demographic variables (mean age, gender ratio, socioeconomic status), as well as the inpatients-outpatients ratio (75% versus 65%), duration of the follow-up (10.5 +/- 2.5 months versus 9.6 +/- 3.2 months), index episode (manic versus mixed), and rates of pharmacologic hypomania did not differentiate the 2 groups. According to stepwise logistic regression, predictors of nonresponse were the presence of comorbidity with conduct disorder (odd ratio, 3.36; 95% CI, 2.20-4.52), attention deficit hyperactivity disorder (ADHD) (odd ratio, 2.30; CI, 1.24-3.26), and the baseline CGI Severity score (odd ratio, 2.31; CI, 1.33-3.29). It is relevant to point out that patient age at the onset of BD, and at the first visit, and comorbid anxiety disorders did not influence treatment response. Follow-up studies with a larger sample size with BD and/or externalizing disorders appropriately managed with different treatment options and/or combinations are warranted.

Pediatric bipolar disorder: phenomenology and course of illness

BACKGROUND

Specific features and diagnostic boundaries of childhood bipolar disorder (BD) remain controversial, and its differentiation from other disorders challenging, owing to high comorbidity with other common childhood disorders, and frequent lack of an episodic course typical of adult BD.

METHODS

We repeatedly examined children meeting DSM-IV criteria for BD (excluding episode-duration requirements) and analyzed their clinical records to evaluate age-at-onset, family history, symptoms, course, and comorbidity.

RESULTS

Of 82 juveniles (aged 10.6 +/- 3.6 years) diagnosed with BD, 90% had a family history of mood or substance-use disorders, but only 10% of patients had been diagnosed with BD. In 74%, psychopathology was recognized before age 3, usually as mood and sleep disturbances, hyperactivity, aggression, and anxiety. At onset, dysphoric-manic and mixed presentations were most common (48%), euphoric mania less (35%), and depression least (17%). Subtype diagnoses were: BP-I (52%) > BP-II (40%) > cyclothymia (7%). DSM episode-duration criteria were met in 52% of cases, and frequent shifts of mood and energy were common.

LIMITATIONS

Partly retrospective study of clinically diagnosed referred outpatients without a comparison group.

CONCLUSIONS

Pediatric BD is often mis- or undiagnosed, although it often manifests with mood lability and sleep disturbances early in life. DSM BD criteria inconsistent with clinical findings require revision for pediatric application.

Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years

OBJECTIVE

To compare the diagnostic efficiency of six index tests as predictors of juvenile bipolar disorder in two large outpatient samples, aged 5 to 10 and 11 to 17 years, gathered from 1997 to 2002.

METHOD

DSM-IV diagnosis was based on a semistructured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with the parent and youth sequentially, blind to scores on the index tests. Participants were 318 youths aged 5 to 10 (50% with bipolar diagnoses) and 324 youths aged 11 to 17 (41% with bipolar diagnoses). Areas under the curve (AUCs) from receiver operating characteristic analyses and multilevel likelihood ratios quantified test performance.

RESULTS

Parent report (AUCs from 0.78 to 0.84 in both age groups) outperformed teacher (AUCs 0.57 in the younger sample and 0.70 in the older sample) or adolescent measures (AUCs 0.67 [General Behavior Inventory] and 0.71 [Youth Self-Report]) at identifying bipolar disorders. Combining tests did not produce clinically meaningful classification improvement.

CONCLUSIONS

Parent report was more useful than teacher report or adolescent self-report on the index tests studied. Results generally replicated across both age groups. Parent report on these instruments could facilitate differential diagnosis of bipolar disorder in youths aged 5 to 17 years, especially by decreasing the rate of false-positive diagnoses.

Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: bipolar disorders

Although it was assumed for many years that children do not experience bipolar disorder, it has been recently recognized that some children do. Those who have been severely maltreated may be at an increased risk for developing a bipolar disorder. This article explores the symptoms of the bipolar disorder as well as strategies for distinguishing these symptoms from those of children experiencing more common disorders. Treatment strategies, including the use of medication, for children experiencing bipolar disorder and their families are examined.

Irritability in pediatric mania and other childhood psychopathology

Irritability is an important symptom in childhood psychopathology that has received relatively little research attention. Recent controversy concerning the diagnosis of mania in children has focused attention on how little is known about how to assess irritability in a systematic way, and about its diagnostic associations. For example, subtyping irritability according to course (chronic vs. episodic), precipitants, and family history may facilitate the identification of psychopathology and the study of pathophysiology. While normative and pathologic irritability can be differentiated reliably, the validity of the distinction is unclear. In addition, there is a need for scales designed to measure the severity of irritability in children with mood and anxiety disorders. In order to facilitate research, we propose a definition of irritability from the perspective of affective neuroscience. Because reactive aggression may be a helpful animal model for irritability, we review the neural circuitry mediating this behavior. Behavioral paradigms that evoke frustration, as well as those that assess the ability to inhibit a prepotent motor response, maintain attentional focus, execute response reversal, recognize angry faces, and regulate emotional responses, may be useful in the study of irritability. Examples of such paradigms are described, and the pharmacology of irritability is reviewed briefly.

Clinical correlates of episodicity in juvenile mania

OBJECTIVE

Researchers debate whether the diagnostic criteria for mania should differ between children and adults. Specifically, although the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM-IV) requires episodic mood changes, children commonly are diagnosed as manic on the basis of chronic irritability. In this preliminary study, children carrying a diagnosis of bipolar disorder (BPD) in the community were classified as having either episodic or chronic symptoms. We hypothesized that the episodic group would be more likely to have a history of psychosis and a parental history of BPD, whereas the chronic group would be more likely to have conduct disorder.

METHODS

Parents of children carrying the BPD diagnosis were interviewed on the telephone to obtain psychiatric and family histories. Children were considered episodic (n = 34) if they had a history of one or more DSM-IV manic/hypomanic episodes meeting full duration criteria and chronic (n = 53) if they had no discernable episodes.

RESULTS

The episodic group was more likely to have had psychosis, parental history of BPD, and to have experienced each manic symptom except for irritability and psychomotor agitation. Children in the episodic group were also more likely to have had a depressive episode meeting full DSM-IV criteria and were more likely to have made a suicide attempt. Children in the chronic group were not more likely to meet criteria for conduct disorder but were more likely to exhibit violence toward others.

CONCLUSIONS

These preliminary data indicate that, among children being treated for BPD in the community, those with discrete episodes of mania may be more likely to have a lifetime history of psychosis and a parental history of BPD. The latter hypothesis should be tested in a sample where relatives are interviewed directly.

Medication use in children and adolescents treated in the community for bipolar disorder

We assessed the use of mood stabilizers, stimulants, antipsychotic medication, and selective serotonin reuptake inhibitors in children being treated in the community for bipolar disorder (BPD). One hundred eleven patients were screened via parent phone interview for possible inclusion in a phenomenological study of BPD. Data were obtained on the patients' medication trials and side effects. The results of the study indicated that children and adolescents who carry a diagnosis of BPD are treated with a mean of 3.40 +/- 1.48 medications and have had a mean of 6.32 +/- 3.67 trials of psychotropic medication in the past. Ninety-eight percent have had a trial of a mood stabilizer or anticonvulsant, with the most common being valproate (79%), lithium (51%), and gabapentin (29%).

Employing parent, teacher, and youth self-report checklists in identifying pediatric bipolar spectrum disorders: an examination of diagnostic accuracy and clinical utility

The diagnosis of bipolar spectrum disorders (BPSD) is difficult to evaluate in child and adolescent populations. The current study examines whether commonly used behavior checklists- the Child Behavior Checklist, Teacher Report Form, and the Youth Self-Report form-are clinically useful in making a differential diagnosis between BPSD and other disorders. This study is the first to investigate the validity of integrating pairs of informants using these instruments to differentiate individuals with BPSD from those with disruptive behavior disorders, major depressive disorder, and any child or adolescent not meeting criteria for BPSD. Parent report best predicted diagnostic status, yet diagnostic efficiency statistics associated with these checklists were relatively poor. Results indicate that the Child Behavior Checklist has limited utility when attempting to derive clinically meaningful information about the presentation of juvenile BPSD.

Mania in six preschool children

At least nine cases of apparent preschool manic-depressive illness have been previously reported in the literature. In each of these children, a strong family history of affective illness was noted. In this report, the case histories of six preschool children ages 3 to 5 years with bipolar illness are summarized. These six were obtained from a sample of 36 consecutively hospitalized preschool children. Thus 17% of these hospitalized preschool children had bipolar illness. All had irritable mood, strong family history of affective illness, and previous presentation with symptoms of attention deficit hyperactivity disorder. They were diagnosed following a thorough clinical interview. Five children were treated with lithium; all five improved. Preschool mania exists as an identifiable entity and may respond to classic pharmacologic treatments.

Neuropsychological performance in pediatric bipolar disorder

BACKGROUND

Growing awareness of childhood bipolar disorder necessitates further cognitive neuroscience research to determine unique developmental differences between pediatric and adult onset bipolar disorder. We sought to examine whether neuropsychological function in children with bipolar disorder resembles that in adults with the illness and to extend our knowledge about cognitive function in pediatric bipolar disorder.

METHODS

We administered a computerized neuropsychological test battery known as the Cambridge Neuropsychological Test Automated Battery to a sample of 21 children and adolescents with bipolar disorder and compared them with 21 age- and gender-matched controls.

RESULTS

In comparison to controls, children with bipolar disorder were impaired on measures of attentional set-shifting and visuospatial memory. Post hoc analyses in pediatric bipolar disorder subjects did not show significant associations between neuropsychological performance and manic symptomatology or attention-deficit/hyperactivity disorder comorbidity.

CONCLUSIONS

Cambridge Neuropsychological Test Automated Battery data presented here in pediatric bipolar disorder fit well within the broader framework of known neurocognitive deficits in adult bipolar disorder. Our pediatric bipolar disorder subjects demonstrated selective deficiencies in attentional set-shifting and visuospatial memory. Our work suggests altered ventrolateral prefrontal cortex function, especially when linked to other lesion and neuroimaging studies.

No evidence of attentional deficits in stabilized bipolar youth relative to unipolar and control comparators

OBJECTIVE

The purpose of this study was to determine the presence or absence of attentional problems and prior diagnosis of ADHD in a cohort of stabilized bipolar I relative to unipolar and normal control.

METHOD

Indices of attention were obtained from bipolar (n = 44), unipolar (n = 30), and normal controls (n = 45). Measures included: Freedom from Distractibility (FD) Composite Index of the WISC III, Conners' Continuous Performance Test (CPT), Wisconsin Card Sorting Test (WCST), and a checklist measure of subjective cognitive/attentional problems (SIP-AV).

RESULTS

Bipolar (6.8%), unipolar (10%), and no control youth report a prior diagnosis of ADHD. No significant group or sex differences were observed on FD Composite Index, various CPT indices, or the WCST. Despite normative attentional function by objective testing, subjectively experienced cognitive problems in the clinical probands were reported.

CONCLUSIONS

This cohort of well-functioning bipolar youth diagnosed on average 3-4 years prior to assessment do not possess attentional deficits based on a variety of objective tests compared to unipolar or control youth, but self report subjective difficulties in attentional/problem solving ability. In contrast to other authors, we do not find that bipolar youth have high rates of comorbid ADHD.

Methodological issues and controversies in clinical trials with child and adolescent patients with bipolar disorder: report of a consensus conference

OBJECTIVE

To achieve consensus among researchers, pharmaceutical industry representatives, federal regulatory agency staff, and family advocates on a template for clinical trials of acute mania/bipolar disorder in children and adolescents.

METHOD

The American Academy of Child and Adolescent Psychiatry, in collaboration with Best Practice, convened a group of experts from the key stakeholder communities (including adult psychiatrists with expertise in bipolar disorder) and assigned them to workgroups to examine core methodological issues surrounding the design of clinical trials and, ultimately, to generate a consensus statement encompassing: (1) inclusion/exclusion criteria, (2) investigator training needs and site selection, (3) assessment and outcome measures, (4) protocol design and ethical issues unique to trials involving children/adolescents, and (5) regulatory agency perspectives on these deliberations.

RESULTS

Conference participants reached agreement on 18 broad methodological questions. Key points of consensus were to assign priority to placebo-controlled studies of acute manic episodes in children and adolescents aged 10-17 years, who may or may not be hospitalized, and who may or may not suffer from common comorbid psychiatric disorders; to require that specialist diagnostic "gatekeepers" screen youths' eligibility to participate in trials; to monitor interviewer and rater competency over the course of the trial using agreed upon standards; and to develop new tools for assessment, including scales to measure aggression/rage and cognitive function, while using the best available instruments (e.g., Young Mania Rating Scale) in the interim.

CONCLUSIONS

Methodologically rigorous, large-scale clinical trials of treatment of acute mania are urgently needed to provide information regarding the safety and efficacy, in youth, of diverse agents with potential mood-stabilizing properties.

Prospective study of prodromal features for bipolarity in well Amish children

OBJECTIVE

A prospective study of psychiatrically well Amish children to determine differences in the frequency and pattern of clinical features that may be prodromal for bipolar I disorder.

METHOD

Children with a bipolar I parent (n = 100) and children of well parents in a matched control sample (n = 110) were assessed annually for 7 years with semistructured interviews covering medical/developmental features and symptoms/behaviors that are possibly prodromal for bipolarity. Randomized histories of these 210 children were evaluated blindly by 4 clinicians for independent ratings of risk for bipolarity.

RESULTS

Thirty-eight percent of the children of bipolar parents were rated as at risk compared with 17% of children in the control sample. Most control sample children with risk ratings had well parents with a bipolar sibling (i.e., family history positive). Children with family histories negative for mental illness rarely received even a low risk rating. Clinical features significantly (p <or=.05) more frequent among children of a bipolar parent included mood lability, low energy, anxious/worried, hyper-alert, attention problems/distractible and school role impairment, easily excited, sensitivity, somatic complaints, and stubborn/determined.

CONCLUSION

Mini-clusters of early possible predictors suggest a natural history of episodic prodromal features rather than the chronic symptom pattern sometimes described for children at risk for bipolar disorder.

Is preadolescent mania the same condition as adult mania? A British perspective

Until relatively recently, the prevailing view was that mania was uncommon in preadolescent children. In the past 15 years, however, there has been increasing interest in the idea that mania may be much more common at younger ages than previously recognized. This article is concerned with the issue of whether preadolescent mania represents the same kind of problem as adult mania. It reviews concepts of bipolar disorder and mania in adults and preadolescents, some of the issue that arise in diagnosing mania in children, and the evidence for continuities between preadolescent and adult mania. The diagnosis of mania in preadolescent children often requires that inferences are made about the meaning of some symptoms but it is not always clear that these inferences are valid. It is concluded that the extant evidence does not provide a clear conclusion about the links between preadolescent and adult mania. More work is needed on the phenomenology and diagnosis of mania in children, on its natural history and on its familial correlates.

Manic symptoms in young males with ADHD predict functioning but not diagnosis after 6 years

OBJECTIVE

To compare the outcome in early adulthood of males who met criteria for attention-deficit/hyperactivity disorder (ADHD) and mania, ADHD alone, or no psychiatric disorder when aged 9-13 years.

METHOD

Males who met criteria at baseline assessment conducted in the period 1992-1994 for mania+ADHD (n = 15), ADHD without mania (n = 65), or no psychiatric diagnosis (n = 17) were reevaluated after 6 years using computer-assisted structured interviews for Axis I and Axis II disorders, questionnaires about functioning and service utilization, and a clinician-rated assessment of global functioning.

RESULTS

There were no group differences in the prevalence of Axis I or Axis II disorders, with the exception of alcohol abuse, which was higher in controls. Manic symptoms persisted in only one mania+ADHD subject, while three (5%) of the ADHD subjects had new-onset manic symptoms. There were no clear cases of bipolar disorder. The groups were not distinguished on levels of service utilization or criminal behavior, but global functioning was significantly lower at follow-up in the mania+ADHD group compared with controls.

CONCLUSIONS

Although a pilot study in scope, the findings cast doubt on a link between mania symptoms associated with ADHD in childhood and later bipolar disorder.

A psychopathological study into the relationship between attention deficit hyperactivity disorder in adult patients and recurrent brief depression

OBJECTIVE

Clinical and epidemiological observations and neurobiological data suggest that there might be an inherent link between attention deficit hyperactivity disorder (ADHD) and recurrent brief depression (RBD). In this psychopathological study, we investigated the comorbidity between these two conditions.

METHOD

Using an index patient approach 40 adult out-patients fulfilling the criteria for ADHD were investigated for lifetime history of RBD and another 40 out-patients with the primary diagnosis of RBD were investigated for a lifetime history of ADHD.

RESULTS

We found a high prevalence of RBD in patients with ADHD (70%) while the prevalence of ADHD in the index sample with RBD was smaller (about 40%).

CONCLUSION

In terms of comorbidity ADHD was the second commonest psychiatric disorder in patients with RBD next to other affective disorders. The psychopathological pattern of lifetime comorbidity might be of clinical relevance in terms of medical treatment.

Discriminative validity of the general behavior inventory using youth report

The present study investigated the ability of the General Behavior Inventory (GBI) to discriminate between diagnostic groups using youth self-report. One hundred and ninety-seven youths ages 10-17 years presenting at a midwestern urban outpatient clinic specializing in mood disorders completed the GBI as part of the intake process. Diagnoses were determined by a structured clinical interview (K-SADS) administered by either a child and adolescent psychiatrist or a research assistant trained to a high level of interrater reliability (kappa > .85). Games-Howell post hoc tests showed that the diagnostic groups significantly differed on the GBI's 2 subscales, Depression and Hypomanic-Biphasic. Logistic regression demonstrated that the scales discriminated between bipolar and disruptive behavior disorders, unipolar and bipolar depression, and mood and disruptive behavior disorders or no diagnosis. Receiver Operating Characteristic (ROC) curves further indicated the good diagnostic efficiency of the scales. Results indicate that the GBI's subscales might aid in making traditionally difficult differential diagnoses, such as between bipolar disorder and Attention Deficit Hyperactivity Disorder (ADHD) and between unipolar and bipolar depression.

Discriminative validity of a parent version of the Young Mania Rating Scale

OBJECTIVE

To examine the usefulness of a parent report version of the Young Mania Rating Scale (P-YMRS) in distinguishing bipolar disorder from other mental health conditions in children and adolescents.

METHOD

Parents of 117 youths aged 5 to 17 years presenting to an outpatient research center completed an adapted Young Mania Rating Scale (P-YMRS). Eligible subjects underwent a diagnostic evaluation including a semistructured instrument (Schedule for Affective Disorders and Schizophrenia for School-Age Children) and also a clinical evaluation by a child and adolescent psychiatrist in more than 75% of the subjects.

RESULTS

Factor analyses of the P-YMRS suggested one dimension, with a total score showing acceptable internal consistency (alpha =.75). Logistic regressions discriminated bipolar mood disorder versus unipolar disorder, versus disruptive behavior disorder, and versus any other diagnosis. Classification rates exceeded 78%, and receiver operating characteristics analyses showed good diagnostic efficiency, with areas under the curve greater than 0.82.

CONCLUSIONS

The P-YMRS may be used to derive clinically meaningful information about mood disorders in youths.

Severity of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant treatment

BACKGROUND

Childhood bipolarity (BP) and ADHD frequently co-occur, these children often receive stimulants.

METHOD

We retrospectively evaluated 80 adolescents hospitalized with BP, manic or mixed, assessed severity of hospital course, and compared groups according to current/past stimulant or antidepressant treatment.

RESULTS

Lifetime ADHD rate was 49%; 35% of patients had exposure to stimulants and 44% to antidepressants. Stimulant-exposed patients were younger than non-exposed (mean+/-S.D.=13.7+/-2 vs. 15.1+/-2 years, Z=-3.1, P=0.002). Only stimulant exposure was associated with worse hospitalization course (MANCOVA, Wilks' Lambda=0.87, F=3.4; df=70; P=0.02).

CONCLUSION

Stimulant-exposed BP-adolescents may have more severe illness course not fully explained by ADHD comorbidity.

LIMITATIONS

Retrospective methodology and lack of structured interviewing make it difficult to quantify exposure to stimulants and antidepressants.

Childhood mania, attention deficit hyperactivity disorder and conduct disorder: a critical review of diagnostic dilemmas

OBJECTIVES

Significant debate exists on whether early onset bipolar disorder is mistakenly attributed to attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or whether ADHD and CD are frequently misdiagnosed as mania. We review the literature on the extent to which these disorders can be reliably differentiated, and describe the diagnostic confusion that may be the result of features common to both classes of disorders.

METHODS

The review focuses on research studies that have examined whether overlapping symptoms of bipolar disorder, ADHD, and CD contribute to misdiagnosis of the two classes of disorders, the prevalence of early onset bipolar disorder with comorbid ADHD or CD, and theories regarding the origins of this comorbidity.

RESULTS

Reliable and accurate diagnoses can be made despite the symptom overlap of bipolar disorder with ADHD and CD. Children with bipolar disorder and ADHD may have a distinct familial subtype of bipolar disorder. Some findings suggest that manic symptoms may represent 'noise' that indicates the general severity of psychopathology in a child or adolescent.

CONCLUSIONS

Further prospective studies may confirm whether early onset bipolarity can be successfully differentiated from ADHD or CD, whether all three types of disorders can be recognized in comorbid cases, or whether comorbid cases represent a distinct subtype of bipolar disorder.

Psychiatric disturbances in children of parents with bipolar disorder

The early symptoms of bipolar disorder in children and adolescents are often qualitatively different from the classic symptoms of mania and depression that present in adults, complicating the diagnosis of the disorder in younger populations. The focus of this article is the evaluation and treatment of children with bipolar parents who begin to develop behavioral and other psychiatric problems. The authors first review the current criteria available for diagnosing bipolar disorder in children. They consider issues related to how the DSM-IV criteria have been applied in this population, in particular the increase in the number of children diagnosed with bipolar disorder as a result of the decision to allow a "manic" episode to be diagnosed in the absence of expansive or elated mood. The practice parameters for the diagnosis and treatment of bipolar disorder in children and adolescents developed by the American Academy of Child and Adolescent Psychiatry are also discussed. The literature concerning children of parents with bipolar disorder is reviewed and indicates that these children are at increased risk for a wide range of psychiatric disorders, including bipolar disorders, other affective disorders, disruptive behavior disorders, and other psychiatric illnesses. The authors then review what is known about treatment for the early symptoms of bipolar disorder in this population and discuss the utility of mood stabilizers. The authors then discuss the role genomic screening may play in the future in identifying children at the highest risk for developing bipolar disorder. The article concludes with a summary of several endophenotypic expressions of bipolar disorder that have been described in children of parents with bipolar disorder.

Clinical decision-making using the General Behavior Inventory in juvenile bipolarity

OBJECTIVE

The General Behavior Inventory (GBI) is a questionnaire that has utility in the assessment of mood disorders in adults. The purpose of this study was to examine how the GBI might optimally be used in the assessment of youths.

METHOD

Children and adolescents between the ages of 5 and 17 years participated in this study. All youths were evaluated with the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). Based on the K-SADS results, subjects were then assigned to one of four groups: a bipolar spectrum group, a depressive disorders group, a disruptive behaviors disorders group, and a no diagnosis group. Guardians completed a version of the GBI modified for parent reporting. Patients 10 years old or greater also completed the GBI as a self-report measure.

RESULTS

There were 196 subjects who participated. Both parent report and youth self-report assigned patients to the appropriate diagnostic group with better than 74% accuracy. Combining information from multiple informants did not significantly improve diagnostic group assignment.

CONCLUSIONS

These data suggest that the GBI may be a useful adjunct in the diagnosis of mood disorders in youths, particularly when diagnostic specificity is more important than sensitivity.