The diagnosis of preschool bipolar disorder presenting with mania: open pharmacological treatment

Deficient Emotional Self-Regulation in Preschoolers With ADHD: Identification, Comorbidity, and Interpersonal Functioning

OBJECTIVE

This study aims to develop an age-adjusted Child Behavior Checklist- (CBCL) and Teacher Report Form (TRF)-based method for the detection of deficient emotional self-regulation (DESR) in preschoolers with ADHD and to assess its incidence, comorbidities, and consequences on interpersonal functioning.

METHOD

Eighty-six ADHD preschoolers and 104 controls were assessed using CBCL, TRF/1½ to 5, Psychiatric Interview With Preschool Age Psychiatric Assessment, Leiter-R, and ADHD rating scales.

RESULTS

Greatest sensitivity and specificity were obtained applying slightly lower threshold scores compared with school-age children (CBCL: Anxiety/Depression [A/D] ≥ 59, Attention Problems [AP] ≥ 60, Aggression Behaviors [AB] ≥ 58; TRF: A/D ≥ 59, AP ≥ 60, AB ≥ 60). DESR was detected in 33/86 (38.4%) and in 16/54 (29.6%) ADHD preschoolers versus 2/104 (1.9%) controls using CBCL and TRF, respectively. DESR is associated with significantly greater comorbidity and impairment in interpersonal functioning.

CONCLUSION

Among ADHD preschoolers, DESR (a) requires lower CBCL and TRF threshold scores for detection, compared with school-age children, (b) displays similar incidence rates, and (c) is associated with enhanced psychiatric comorbidity and interpersonal difficulties.

Pediatric Mania: The Controversy between Euphoria and Irritability

Abstract: Pediatric Bipolar Disorder (BD) is a highly morbid pediatric psychiatric disease, consistently associated with family psychiatric history of mood disorders and associated with high levels of morbidity and disability and with a great risk of suicide. While there is a general consensus on the symptomatology of depression in childhood, the phenomenology of pediatric mania is still highly debated and the course and long-term outcome of pediatric BD still need to be clarified. We reviewed the available studies on the phenomenology of pediatric mania with the aim of summarizing the prevalence, demographics, clinical correlates and course of these two types of pediatric mania. Eighteen studies reported the number of subjects presenting with either irritable or elated mood during mania. Irritability has been reported to be the most frequent clinical feature of pediatric mania reaching a sensitivity of 95–100% in several samples. Only half the studies reviewed reported on number of episodes or cycling patterns and the described course was mostly chronic and ultra-rapid whereas the classical episodic presentation was less common.

Few long-term outcome studies have reported a diagnostic stability of mania from childhood to young adult age. Future research should focus on the heterogeneity of irritability aiming at differentiating distinct subtypes of pediatric psychiatric disorders with distinct phenomenology, course, outcome and biomarkers. Longitudinal studies of samples attending to mood presentation, irritable versus elated, and course, chronic versus episodic, may help clarify whether these are meaningful distinctions in the course, treatment and outcome of pediatric onset bipolar disorder.

[Internal consistency and criterion validity and reliability of the Mexican Version of the Child Behavior Checklist 1.5-5 (CBCL/1.5-5)]

OBJECTIVE

To investigate the validity and internal consistency of the Mexican version of the CBCL/1.5 -5 that assesses the most common psychopathology in pre-school children in clinical and epidemiological settings.

PATIENTS AND METHOD

A total of 438 parents from two groups, clinical-psychiatric (N= 62) and community (N= 376) completed the CBCL/1.5-5/Mexican version.

RESULTS

The internal consistency was high for total problems α=0.95, and internalized α=0.89 and externalized α=0.91 subscales. The test re-test (one week) using the intraclass correlation coefficient (ICC) was ≥ 0.95 for the internalized, externalized, and total problems subscales. The ROC curve for the criterion status of clinically-referred vs. non-referred using the total problems scale ≥ 24 resulted in an AUC (area under curve) of 0.77, a specificity 0.73, and a sensitivity of 0.70.

CONCLUSIONS

The CBCL/1.5 -5/Mexican version is a reliable and valid tool.

Bipolar disorders following initial depression: modeling predictive clinical factors

OBJECTIVE

Most first lifetime episodes among persons eventually diagnosed with bipolar disorder are depressive, often with years of delay to a final differentiation from unipolar major depression. To support early differentiation, we tested several predictive factors for association with later diagnoses of bipolar disorder.

METHOD

With data from mood-disorder patients with first-lifetime episodes of major depression, we used multivariate, logistic modeling and Bayesian methods including Receiver Operating Characteristic curves to evaluate ability of one or more selected factors to differentiate patients who later met DSM-IV-TR diagnostic criteria for bipolar disorder and not unipolar major depressive disorder.

RESULTS

We analyzed data from 2146 patients (642 bipolar, 1504 unipolar) at risk for 13 years following initial depressive episodes. In multivariate modeling for 812 subjects with information on all clinical factors considered, seven significantly and independently differentiated bipolar from unipolar disorders, ranking (by significance): (a) ≥4 previous depressive episodes, (b) suicidal acts, (c) cyclothymic temperament, (d) family history of bipolar disorder, (e) substance-abuse, (f) younger-at-onset, or onset-age <25, and (g) male sex; four of these (c, d, f, g) can be identified at illness-onset. Bayesian analysis indicated optimal sensitivity and specificity at 2-4 factors/person and correct classification of 64-67% of cases, and ROC analysis of factors/person yielded a significant area-under-the-curve of 0.72 [CI: 0.68-0.75].

CONCLUSIONS

In multivariate modeling, 7 factors were significantly and independently associated with bipolar disorder diagnosed up to 13 years after initial depression.

Placebo-controlled trial of valproic Acid versus risperidone in children 3-7 years of age with bipolar I disorder

OBJECTIVE

The objective of this study was to determine the efficacy and safety of valproic acid versus risperidone in children, 3-7 years of age, with bipolar I disorder (BPD), during a mixed or manic episode.

METHODS

Forty-six children with Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision (DSM-IV-TR) diagnosis of bipolar disorder, manic, hypomanic, or mixed episode, were recruited over a 6 year period from two academic outpatient programs for a double-blinded, placebo-controlled trial in which subjects were randomized in a 2:2:1 ratio to risperidone solution, valproic acid, or placebo.

RESULTS

After 6 weeks of treatment, the least-mean Young Mania Rating Scale (YMRS) total scores change, adjusted for baseline YMRS scores, from baseline by treatment group was: Valproic acid 10.0±2.46 (p=0.50); risperidone 18.82±1.55 (p=0.008); and placebo 4.29±3.56 (F=3.93, p=0.02). The mixed models for repeated measure (MMRM) analysis found a significant difference for risperidone-treated subjects versus placebo treated subjects (p=0.008) but not for valproic acid-treated subjects versus placebo-treated subjects (p=0.50). Treatment with risperidone over 6 weeks led to increased prolactin levels, liver functions, metabolic measures, and weight/body mass index (BMI). Treatment with valproic acid led to increases in weight/BMI and decreases in total red blood cells (RBC), hemoglobin, and hematocrit.

CONCLUSIONS

In this small sample of preschool children with BPD, risperidone demonstrated clear efficacy versus placebo, whereas valproic acid did not. The laboratory and weight findings suggest that younger children with BPD are more sensitive to the effects of both of these psychotropics, and that, therefore, frequent laboratory and weight monitoring are warranted.

Bipolar disorder in children

Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.

Bipolar Disorder in Children and Adolescents Recognised in the UK: A Clinic-Based Study

BACKGROUND

  Diagnoses of paediatric bipolar disorder have increased over the last two decades in the United States, where high levels of comorbidity with ADHD have also been reported.

AIMS

  To explore how British clinicians apply these diagnoses.

METHOD

  We compared 378 young people under the age of 18 who received a diagnosis of bipolar disorder and/or ADHD from a large NHS mental health trust between 1992 and 2007.

RESULTS

  Children with bipolar disorder were rare in this sample (n = 35, 1.0%), particularly under the age of 13 (n = 9, 0.3%). Children with bipolar disorder presented more often with affective and psychotic symptoms than children with ADHD. Irritability was common in both disorders. Core ADHD symptoms were prevalent in both conditions but occurred in a greater proportion of children with ADHD.

CONCLUSION

  Our findings suggest that psychiatrists in England use the traditional adult criteria of bipolar disorder rather than the broader criteria being adopted by some practitioners in the US.

Psychometric properties of the Young Mania Rating Scale for the identification of mania symptoms in Spanish children and adolescents with attention deficit/hyperactivity disorder

BACKGROUND

Diagnosing mania in children is difficult, due to the high comorbidity and symptom overlap with attention deficit/hyperactivity disorder (ADHD). The detection of manic symptoms in ADHD has important implications for prognosis and choice of treatment. Our objective was to study the utility of the Young Mania Rating Scale (YMRS) for discriminating mania in Spanish children with ADHD.

METHOD

One hundred children and adolescents with ADHD between 8 and 17 years of age were evaluated with a structured diagnostic interview (Diagnostic Interview for Children and Adolescents-IV), the YMRS, the Parent-Young Mania Rating Scale (P-YMRS), the Child Mania Rating Scale-Parent Version (CMRS-P) and the Children's Global Assessment Scale.

RESULTS

The YMRS showed a 1-dimensional structure with good internal consistency and test-retest reliability. The YMRS was associated with the P-YMRS and the CMRS-P. The scores obtained with the YMRS differentiated between ADHD with and without mania. The receiver operating characteristic curve analysis showed good diagnostic efficiency in differentiating mania in ADHD (area under the curve of 0.90).

CONCLUSIONS

The Spanish version of the YMRS is a valid and reliable instrument for detecting and quantifying the symptoms of mania in children and adolescents with ADHD. The results provide further knowledge about the frequent association between ADHD and manic symptoms in children.

Bipolar disorder in young people: Description, assessment and evidence-based treatment

OBJECTIVE

The literature on bipolar in children and adolescents was reviewed to provide an update for clinicians.

REVIEW PROCESS

Literature of particular relevance to evidence-based practice was selected for critical review.

OUTCOMES

An up-to-date overview of clinical features, epidemiology, prognosis, aetiology, assessment and intervention was provided.

CONCLUSIONS

Bipolar disorder in children and adolescence is a relatively common, multifactorially determined and recurring problem which persists into adulthood. Psychometrically robust screening questionnaires and structured interviews facilitate reliable assessment. Multimodal chronic care programmes involving medication (notably lithium) and family-oriented psychotherapy are currently the treatment of choice.

Pharmacological response in juvenile bipolar disorder subtypes: A naturalistic retrospective examination

This study reports on the naturalistic pharmacotherapy of 266 youths with bipolar disorder (BP), manic or hypomanic episode (158 males and 108 females, 13.8+/-2.8 years), first treated with monotherapy on valproic acid (VPA) (n=158, 59.4%), lithium (n=90, 33.8%) or atypical antipsychotics (n=18, 6.8%). Among the patients receiving mood stabilizers, 59.5% of those treated with VPA and 47.8% of those receiving lithium did not need other antimanic agents (mood stabilizers and/or atypical antipsychotics). Lower severity was associated with a greater persistence of both VPA and lithium monotherapy. Factors associated with greater persistence of VPA monotherapy were BP II and co-occurring generalized anxiety disorder, separation anxiety disorder and simple phobias. On the contrary, BP I and co-occurring psychotic symptoms and/or conduct disorder were associated with a lower persistence of VPA monotherapy. Factors associated with lower persistence of lithium monotherapy were younger age and the association with attention deficit hyper-activity disorder (ADHD). Type of BP and presence of psychotic symptoms and conduct disorder did not affect the lithium monotherapy. Overall, predictors of non-response (multiple stepwise logistic regression) in both VPA and lithium groups were baseline Clinical Global Impression (CGI) Severity score and comorbid conduct disorder; while psychotic symptoms and absence of comorbid generalized anxiety disorder were predictors of poorer treatment response only in the VPA group, and chronic course, comorbid ADHD and absence of comorbid panic disorder were predictors only in the lithium group. Such naturalistic data from an ordinary clinical setting have relevance to clinical practice.

Pediatric bipolar disorder: evidence for prodromal states and early markers

BACKGROUND

Childhood bipolar disorder remains a controversial but increasingly diagnosed disorder that is associated with significant impairment, chronic course and treatment resistance. Therefore, the search for prodromes or early markers of risk for later childhood bipolar disorder may be of great importance for prevention and/or early identification.

METHODS

Literature searches were conducted to identify reviews, case reports and empirical papers addressing the issue of prodromes of childhood bipolar disorder.

RESULTS

A total of 54 articles were found that related to bipolar prodromes, risk factors for later childhood bipolar disorder, childhood risk for adult bipolar disorder, mania manifestations in early childhood, and neuropsychological and biological markers of childhood bipolar disorder. A review of articles suggest (a) childhood bipolar prodromes may be detectable prior to the onset of the disorder, (b) prodromal symptoms may display episodicity during childhood, (c) there is evidence of possible endophenotypic markers such as deficits in executive function, sustained attention, and emotion labeling, (d) there is a potential association with functional, structural, and biochemical alterations evident in brain structures involved in mood regulation, (e) a link between childhood bipolar disorder with early tempermental markers, such as emotional regulation and behavioral disinhibition and (f) there is some early but promising evidence of effective psychotherapeutic preventions.

CONCLUSIONS

There has been very limited investigation of early prodromes of childhood bipolar disorder. Based on the promising findings of prodromes as well as high-risk states and possible endophenotypic markers, more controlled and targeted investigations into the early markers of bipolar disorder appear warranted and potentially fruitful. Until such longitudinal studies with appropriate controls are conducted, specific markers for bipolar prodromes will remain elusive, although evidence suggests they are manifest in at least some subgroups. The finding of promising psychotherapeutic prevention programs underscores the need to find specific and sensitive markers of bipolar prodromes in childhood.

Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study

OBJECTIVE

Little is known about the effect of stimulant treatment in youth with attention-deficit/hyperactivity disorder (ADHD) on the subsequent development of comorbid psychiatric disorders. We tested the association between stimulant treatment and the subsequent development of psychiatric comorbidity in a longitudinal sample of patients with ADHD.

METHODS

We conducted a case-control, 10-year prospective follow-up study into young-adult years of youth with ADHD. At baseline, we assessed consecutively referred white male children with (n = 140) and without (n = 120) ADHD, aged 6 to 18 years. At the 10-year follow-up, 112 (80%) and 105 (88%) of the children in the ADHD and control groups, respectively, were reassessed (mean age: 22 years). We examined the association between stimulant treatment in childhood and adolescence and subsequent comorbid disorders and grade retention by using proportional hazards survival models.

RESULTS

Of the 112 participants with ADHD, 82 (73%) were previously treated with stimulants. Participants with ADHD who were treated with stimulants were significantly less likely to subsequently develop depressive and anxiety disorders and disruptive behavior and less likely to repeat a grade compared with participants with ADHD who were not treated.

CONCLUSIONS

We found evidence that stimulant treatment decreases the risk for subsequent comorbid psychiatric disorders and academic failure in youth with ADHD.

Psychopharmacology and preschoolers: a critical review of current conditions

Rates of prescriptions for very young children have increased notably in the last 20 years. These changes have occurred in the context of increasing attention to early childhood mental health, availability of medications perceived to be safer than older medications, application of the medical model to the mental health care of young children, as well as other cultural shifts. Psychopharmacological treatment for any patient, but especially very young children, requires consideration of central nervous system (CNS) and metabolic development and issues of diagnostic validity and should be guided by an empirical literature. In young children, this literature is quite limited. In this article, the authors review developmental issues involved in psychopharmacological treatment and present existing literature and practical guidelines for common preschool diagnoses, recognizing that for some disorders, the extant literature does not support even consideration of medications.

Preschool Bipolar Disorder

Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder (BPD) remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. While there is a need for well controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3. The need for large scale and focused studies of this issue is underscored by the high and increasing rates of prescriptions of atypical antipsychotics and other mood stabilizing agents for preschool children with presumptive clinical diagnosis of BPD or a related variant. Clarifying the nosology of preschool BPD may also be important to better understand of the developmental psychopathology of the disorder during childhood. Data elucidating this developmental trajectory could then inform the design of earlier potentially preventive interventions that may have implications for the disorder across the lifespan.

Clinical characteristics of bipolar vs. unipolar depression in preschool children: an empirical investigation

BACKGROUND

Despite retrospective reports of the onset of childhood bipolar disorder during the preschool period, few studies have investigated whether mania symptoms can be identified in preschoolers. A group of children with a cluster of mania symptoms that showed discriminant validity from other disruptive disorders was identified in a large preschool sample. These empirical data add to descriptive studies of mania in clinical preschool populations. An investigation of the characteristics of depression among putative bipolar preschoolers may inform the controversial nosologic questions that surround the diagnosis in this young age group.

METHOD

This study, conducted from 2002 to 2007, investigated major depressive disorder (MDD) symptoms and severity in preschoolers with a bipolar syndrome in comparison to those with unipolar MDD, identified by an age-appropriate structured psychiatric interview, the Preschool Age Psychiatric Assessment (based on DSM-IV).

RESULTS

Twenty-one preschoolers were identified who met DSM-IV symptom criteria for bipolar I disorder and MDD and were compared to 54 preschoolers with unipolar MDD. The bipolar depressed preschoolers had significantly higher depression severity (p < .0001) and higher rates of comorbidity than did those with unipolar depression. The study is limited by the exploratory nature of clinical mania characteristics in preschoolers as well as reliance on parent reports of these symptoms.

CONCLUSIONS

These findings suggest that, similar to adult bipolar patients, preschoolers with a putative bipolar syndrome experience clinically significant and severe depression. Symptom characteristics and comorbidity patterns also distinguished this group from the unipolar depressed preschoolers. Our findings underscore the marked depression that characterizes this putative bipolar syndrome and suggest that further investigation of this domain may clarify the nosology of this early-onset disorder.

The impairment of pediatric bipolar sleep: hypotheses regarding a core defect and phenotype-specific sleep disturbances

BACKGROUND

The nature of the sleep disturbances associated with different phenotypes of pediatric bipolar disorder is unknown. Most manic children exhibit delayed sleep onset, but only a minority display decreased need for sleep. The DSM-IV manic sleep criterion is inadequate.

METHOD

All published studies of the sleep characteristics of bipolar children and adolescents are reviewed. Relevant studies of pediatric unipolar depressed subjects, circadian variation of bipolar and sleep variables, and circadian neurobiology are also reviewed. This information forms the basis of hypotheses regarding the core defect of pediatric bipolar sleep and phenotype-specific sleep disturbances of bipolar children and adolescents.

LIMITATIONS

The extant research literature is extremely limited. Interpretation of bipolar sleep is confounded by day-to-day variation of bipolar symptoms and sleep parameters, the presence of comorbid conditions, and environmental and psychosocial factors.

CONCLUSIONS

The core defect of pediatric bipolar sleep is hypothesized to be a significant delay of the circadian sleep-wake cycle, a form of the delayed sleep-phase syndrome. Children and adolescents with part-day manic cycles and chronic mixed conditions typically will manifest delayed sleep onset, but not decreased need for sleep. Pediatric individuals with days-long manic cycles or chronic mania typically will manifest decreased need for sleep, produced by interaction between the sleep-onset phase delay and bedtime and early morning manic psychomotor acceleration. The sleep-onset phase delay, when expressed, is hypothesized to be a trait marker of bipolar spectrum illness. Revision of the DSM-IV manic sleep criterion is necessary.

Pediatric Bipolar Disorder

In the past decade, interest in and research on pediatric bipolar disorder (BD) has increased substantially. Prevalence rates of the disorder have doubled in outpatient settings, while twice as many research articles on pediatric BD were published in the past five years as in the prior decade. This review focuses on recent developments in the study of pediatric BD. We examine current research on the diagnostic boundaries of BD in youths, in particular the issues of episodicity and irritability, and provide assessment guidelines. We review data elucidating the pathophysiology of pediatric BD, with a focus on how these results may inform diagnosis. Finally, we discuss treatment approaches for pediatric BD, particularly psychotherapeutic interventions. Throughout the review, we pay particular attention to youths with severe chronic irritability, hyperarousal, and hyperreactivity, who reflect the population in whom the diagnosis of BD is most debated.

Preschool Bipolar Disorder: Brazilian children case reports

OBJECTIVE

This study describes the clinical phenomenology and family history of preschool age onset Bipolar Disorder (BD).

METHODS

Eight children and adolescents out of 118 cases (6.78%), both genders, meeting current DSM-IV criteria diagnosis of BD were described. The clinical assessment, CBCL, DICA-IV and CGAS were performed directly with each patient and their parents.

RESULTS

Most (87.5%) presented classical symptoms of mania: euphoria, grandiosity, irritability, psychomotor agitation and agitated sleep or, in the same proportion, sleeplessness. Hyperactivity and increase of energy were found in all eight cases. The clinical course varied from a rapid, ultra-rapid, ultradian cycle to a continued pattern. Five out of eight children (62.5%) presented aggressiveness toward others and one deliberate self-harm. Most (87.5%) had psychiatric family history. The average number of medications used during their life was 4.5 drugs.

LIMITATION

The small sample and retrospective reports of the first manic symptoms in three of the cases (cases V, VI and VII).

CONCLUSION

An important incidence of classical manic features was found in very young children. The clinical course tended to be continuous, and preschool BD seems to have a strong association with affective disorder family history.

Psychopharmacological treatment for very young children: contexts and guidelines

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

Three clinical cases of DSM-IV mania symptoms in preschoolers

Despite a growing body of empirical data describing the discriminant and longitudinal validity of mania in older children, little research has been conducted investigating the presence of mania symptoms in preschool-aged children. This report describes three cases of preschool children (ages 3.6 to 5.2) who presented to a subspecialty mental health clinic manifesting age-adjusted mania-like symptoms. Developmental manifestations of DSM-IV mania symptoms described include grandiosity, hypersexuality, elation, racing thoughts, and decreased need for sleep. These symptoms have been shown to be highly specific to distinguish bipolar disorder from attention deficit hyperactivity disorder (ADHD) in older children. Possible manifestations of mood cycling are also described. Clinical observations, parental reports, and related family mental health history are reviewed.

Clinical characteristics of bipolar disorder in very young children

BACKGROUND

Clinical information about bipolar disorder (BPD) in preschool-age (3-7 years old) children is extremely limited. This study examined clinical presentations, applicability of the DSM-IV diagnostic criteria, comorbidity, recovery and relapse rates, as well as some treatment strategies used in the management of BPD in preschoolers.

METHODS

The charts of 26 outpatient children, ages 3-7, refereed to a child psychiatry outpatient clinic with mood and behavioral symptoms, were retrospectively reviewed.

RESULTS

The majority of the patients were referred with the tentative diagnosis of ADHD but the most common diagnoses made by child and adolescent psychiatrists at the time of initial evaluation were BPD NOS (61.5%), followed by BPD I (26.9%), and mood disorder NOS (23.1%). Thirty-eight percent of the patients had one or more comorbid diagnoses. The most common presenting symptoms were irritability (84.6%) and aggression (88.5%). The most widely prescribed class of medications after diagnosis in the clinic was atypical antipsychotics and mood stabilizers. Twenty-six percent of the patients were treated with a combination of atypical antipsychotics and mood stabilizers.

LIMITATIONS

Retrospective design; small sample size; lack of a comparison group.

CONCLUSIONS

The course of BPD with onset in preschool years is complicated with high recovery and relapse rates. The questions of development of age-appropriate diagnostic criteria, long-term prognosis and treatment strategies used in this population require further intensive investigation.

Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder

This practice parameter reviews the literature on the assessment and treatment of children and adolescents with bipolar disorder. The parameter focuses primarily on bipolar 1 disorder because that is the type most often studied in juveniles. The presentation of bipolar disorder in youth, especially children, is often considered atypical compared with that of the classic adult disorder, which is characterized by distinct phases of mania and depression. Children who receive a diagnosis of bipolar disorder in community settings typically present with rapid fluctuations in mood and behavior, often associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders. Thus, at this time it is not clear whether the atypical forms of juvenile mania and the classic adult form of the disorder represent the same illness. The question of diagnostic continuity has important treatment and prognostic implications. Although more controlled trials are needed, mood stabilizers and atypical antipsychotic agents are generally considered the first line of treatment. Although patients may respond to monotherapy, combination pharmacotherapy is necessary for some youth. Behavioral and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the impact of the illness on family and community functioning.

Developmental differences according to age at onset in juvenile bipolar disorder

BACKGROUND

This study on a large sample of unselected, consecutive children and adolescents referred to a third-level hospital who received a diagnosis of bipolar disorder (BD) was aimed at exploring whether childhood-onset BD, as compared with adolescent-onset BD, presents specific clinical features in terms of severity, functional impairment, course, prevalent mood, pattern of co-morbidity, and treatment outcome.

METHODS

A total of 136 patients, 81 males (59.6%) and 55 females (40.4%), mean age 13.5 +/- 2.9 years, meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnosis of BD according to a structured clinical interview Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (KSADS-PL), were included in the study.

RESULTS

Eighty patients (58.8%) had a childhood-onset BD (before 12 years of age) and 56 (41.2%) had an adolescents-onset BD. Compared with the adolescent-onset BD, patients with childhood-onset were more frequently males and had a more frequent co-morbidity with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). An episodic course was found in only 42.5% of bipolar children, but 76.8% of youngsters with adolescent-onset BD. Severity, 6-month treatment outcome, prevalent mood (elated versus irritable), and co-morbid anxiety did not differentiate the two groups.

CONCLUSIONS

Our findings suggest that a very early age at onset may identify a form of BD with a more frequent subcontinuous course and a heavy co-morbidity with ADHD.

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.

Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology

We review recent research on the presentation, nosology and epidemiology of behavioral and emotional psychiatric disorders in preschool children (children ages 2 through 5 years old), focusing on the five most common groups of childhood psychiatric disorders: attention deficit hyperactivity disorders, oppositional defiant and conduct disorders, anxiety disorders, and depressive disorders. We review the various approaches to classifying behavioral and emotional dysregulation in preschoolers and determining the boundaries between normative variation and clinically significant presentations. While highlighting the limitations of the current DSM-IV diagnostic criteria for identifying preschool psychopathology and reviewing alternative diagnostic approaches, we also present evidence supporting the reliability and validity of developmentally appropriate criteria for diagnosing psychiatric disorders in children as young as two years old. Despite the relative lack of research on preschool psychopathology compared with studies of the epidemiology of psychiatric disorders in older children, the current evidence now shows quite convincingly that the rates of the common child psychiatric disorders and the patterns of comorbidity among them in preschoolers are similar to those seen in later childhood. We review the implications of these conclusions for research on the etiology, nosology, and development of early onset of psychiatric disorders, and for targeted treatment, early intervention and prevention with young children.

Delayed diagnosis of pediatric bipolar disorder in a community mental health setting

OBJECTIVE

There is evidence that delayed diagnosis is a significant problem in adult bipolar disorder. It is not known if this also occurs among pediatric patients with this illness. The goal of this study was to determine the frequency of delayed and missed diagnosis of pediatric bipolar disorder in a community mental health setting.

METHOD

Charts of youths with a diagnosis of bipolar I or II disorder, cyclothymia, or bipolar disorder not otherwise specified (NOS) who were treated at a community mental health outpatient clinic between February 2000 and April 2003 were retrospectively reviewed.

RESULTS

The mean number of years from the onset of mood symptoms until diagnosis of bipolar disorder was 5 years (SD = 3.5), with a maximum of 12 years. Only 2 patients (4.8%) received the correct diagnosis within the first year following symptom onset. For 33 patients (78.6%), 2 or more years elapsed, for 22 patients (52.4%) 5 or more years elapsed, and for 7 patients (16.7%) 10 or more years elapsed before they were diagnosed correctly.

CONCLUSIONS

Although the study has several limitations, it suggests that delayed and missed diagnosis may be common among pediatric patients with bipolar disorder who receive treatment in community mental health settings. More rigorous studies are warranted and clinicians who work with pediatric patients should be aware of the risk of misdiagnosis of bipolar disorder in this population.