Can a subtype of conduct disorder linked to bipolar disorder be identified? Integration of findings from the Massachusetts General Hospital Pediatric Psychopharmacology Research Program

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

Examining the clinical correlates of conduct disorder in youth with bipolar disorder

BACKGROUND

Conduct Disorder (CD) is highly comorbid with Bipolar Disorder (BP) and this comorbidity is associated with high morbidity and dysfunction. We sought to better understand the clinical characteristics and familiality of comorbid BP + CD by examining children with BP with and without co-morbid CD.

METHODS

357 subjects with BP were derived from two independent datasets of youth with and without BP. All subjects were evaluated with structured diagnostic interviews, the Child Behavior Checklist (CBCL), and neuropsychological testing. We stratified the sample of subjects with BP by the presence or absence of CD and compared the two groups on measures of psychopathology, school functioning, and neurocognitive functioning. First-degree relatives of subjects with BP +/- CD were compared on rates of psychopathology in relatives.

RESULTS

Subjects with BP + CD compared to BP without CD had significantly more impaired scores on the CBCL Aggressive Behavior (p < 0.001), Attention Problems (p = 0.002), Rule-Breaking Behavior (p < 0.001), Social Problems (p < 0.001), Withdrawn/Depressed clinical scales (p = 0.005), the Externalizing Problems (p < 0.001), and Total Problems composite scales(p < 0.001). Subjects with BP + CD had significantly higher rates of oppositional defiant disorder (ODD) (p = 0.002), any SUD (p < 0.001), and cigarette smoking (p = 0.001). First-degree relatives of subjects with BP + CD had significantly higher rates of CD/ODD/ASPD and cigarette smoking compared to first-degree relatives of subjects without CD.

LIMITATIONS

The generalization of our findings was limited due to a largely homogeneous sample and no CD only comparison group.

CONCLUSIONS

Given the deleterious outcomes associated with comorbid BP + CD, further efforts in identification and treatment are necessary.

Can machine learning identify childhood characteristics that predict future development of bipolar disorder a decade later?

Early identification of bipolar disorder may provide appropriate support and treatment, however there is no current evidence for statistically predicting whether a child will develop bipolar disorder. Machine learning methods offer an opportunity for developing empirically-based predictors of bipolar disorder. This study examined whether bipolar disorder can be predicted using clinical data and machine learning algorithms. 492 children, ages 6-18 at baseline, were recruited from longitudinal case-control family studies. Participants were assessed at baseline, then followed-up after 10 years. In addition to sociodemographic data, children were assessed with psychometric scales, structured diagnostic interviews, and cognitive and social functioning assessments. Using the Balanced Random Forest algorithm, we examined whether the diagnostic outcome of full or subsyndromal bipolar disorder could be predicted from baseline data. 45 children (10%) developed bipolar disorder at follow-up. The model predicted subsequent bipolar disorder with 75% sensitivity, 76% specificity, and an Area Under the Receiver Operating Characteristics of 75%. Predictors best differentiating between children who did or did not develop bipolar disorder were the Child Behavioral Checklist Externalizing and Internalizing behaviors, the Child Behavioral Checklist Total t-score, problematic school functions indexed through the Child Behavioral Checklist School Competence scale, and the Child Behavioral Checklist Anxiety/Depression and Aggression scales. Our study provides the first quantitative model to predict bipolar disorder. Longitudinal prediction may help clinicians assess children with emergent psychopathology for future risk of bipolar disorder, an area of clinical and scientific importance. Machine learning algorithms could be implemented to alert clinicians to risk for bipolar disorder.

Findings from a pilot open-label trial of N-acetylcysteine for the treatment of pediatric mania and hypomania

BACKGROUND

Pediatric bipolar disorder is a highly prevalent and morbid disorder and is considered a prevalent public health concern. Currently approved treatments often pose the risk of serious side effects. Therefore, this study assessed the efficacy and tolerability of N-acetylcysteine (NAC), in children and adolescents with bipolar spectrum disorder.

METHODS

We conducted a 12-week open-label trial of NAC for treatment of mania and hypomania in children and adolescents ages 5-17 with bipolar spectrum disorder including participants with full and subthreshold manic symptoms, accepting those with and without mixed states with co-occurring depression, and Young Mania Rating Scale scores ≥ 20 and < 40. Symptoms of mania and depression were assessed using the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Children's Depression Rating Scale (CDRS), and Clinical Global Impression (CGI) Severity (CGI-S) and Improvement (CGI-I) scales for mania and depression.

RESULTS

This study had a high drop-out rate with only 53% completing all 12 weeks. There was a significant reduction in YMRS, HDRS, and CDRS mean scores from baseline to endpoint. Of the 24 exposed participants, 54% had an anti-manic response measured by a reduction in YMRS ≥ 30% and 46% had a CGI-I mania score ≤ 2 at endpoint. Additionally, 62% of participants had an anti-depressive response measured by a reduction in HDRS ≥ 30%, 31% had an anti-depressive response measured by a reduction in CDRS ≥ 30%, and 38% had a CGI-I depression score ≤ 2 at endpoint.

CONCLUSIONS

These pilot open-label findings in a small sample provide preliminary data supporting the tolerability and safety of NAC in a pediatric population. The findings of this pilot scale study indicating improvement in mania and depression are promising, but require replication with a monotherapy randomized placebo controlled clinical trial and larger sample.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02357290 . First Registration 06/02/2015.

Can pediatric bipolar disorder be successfully treated when comorbid with conduct disorder? A secondary analysis of clinical trials of risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole

BACKGROUND

Pediatric bipolar disorder (BP) is frequently comorbid with conduct disorder (CD) and its presence adds to the morbidity of BP. While there are no known pharmacological treatments for CD, pediatric BP is responsive to treatment with medications initially indicated for the treatment of psychosis, several of which have Food and Drug Administration (FDA) approval for the treatment of pediatric mania.

AIMS

The main aim of this secondary analysis was to examine whether pediatric BP comorbid with CD responds similarly to treatment with such selected medications. Considering the well-documented morbidity of CD, this finding could have important clinical and public health significance.

METHODS

We conducted a secondary analysis of six prospective 8-week open-label trials of selected medications (risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole) using identical methodology in youth with BP with and without comorbid CD. Results: Of 165 youths with BP, 54% (N = 89) met criteria for comorbid CD. The antimanic effects observed did not significantly differ between BP youths with and without comorbid CD, as measured either by a reduction in Young Mania Rating Scale (YMRS) ⩾ 30% or Clinical Global Impression (CGI)-Improvement ⩽ 2 (p = 0.23), or by the more stringent definition of a reduction in YMRS ⩾ 50% (p = 0.61).

CONCLUSION

Pediatric BP can be effectively treated with the abovementioned medications in the context of comorbid CD. Based on previous research showing that remission of BP is associated with remission of CD, if confirmed, these findings raise the possibility that antimanic treatment of youth with BP comorbid with CD could have secondary benefits in mitigating the morbidity associated with CD. This is a pilot scale finding, the results of which are promising and should be confirmed by larger and long-term follow-up studies.

Cognitive correlates of impulsive aggression in youth with pediatric bipolar disorder and bipolar offspring

BACKGROUND

Youth with bipolar disorder (BD) and offspring of individuals with BD (BD-OFF) are characterized by higher levels of impulsive and overt aggression. The cognitive basis underlying these aggressive behaviors are not clarified in this population. The aim of this study was to investigate the relationship between cognitive alterations and aggressive behavior in youth with BD and BD-OFF.

METHODS

Forty-two youth with BD, 17 BD-OFF and 57 healthy controls (HCs) were administered the Modified Overt Aggression Scale (MOAS), the Cambridge Neuropsychological Test Automated Battery (CANTAB), the Young Mania Rating Scale (YMRS) and the Children's Depression Rating Scale (CDRS). Multiple linear regression analyses were performed in the three groups separately. In each group, tests scores from the CANTAB were predictors. MOAS subscale scores and MOAS total scores were dependent variables. Results are corrected for age, IQ and mood state.

RESULTS

Both youth with BD and BD-OFF showed positive correlations between impairment in executive functions and levels of verbal aggression. In youth with BD, altered processing of either positive and negative stimuli positively correlated with MOAS total scores, whereas in BD-OFF, such relationship was negative.

CONCLUSIONS

Impulsive aggressive behaviors in youth with BD arise from a combination of altered affective processing and executive dysfunction. The negative relationship between affective processing and aggression in BD-OFF suggested the presence of possible mechanisms of resilience in this population.

Comorbidity of ADHD and adult bipolar disorder: A systematic review and meta-analysis

Attention-deficit / hyperactivity disorder (ADHD) and Bipolar Disorder (BD) are common mental disorders with a high degree of comorbidity. However, no systematic review with meta-analysis has aimed to quantify the degree of comorbidity between both disorders. To this end we performed a systematic search of the literature in October 2020. In a meta-analysis of 71 studies with 646,766 participants from 18 countries, it was found that about one in thirteen adults with ADHD was also diagnosed with BD (7.95 %; 95 % CI: 5.31-11.06), and nearly one in six adults with BD had ADHD (17.11 %; 95 % CI: 13.05-21.59 %). Substantial heterogeneity of comorbidity rates was present, highlighting the importance of contextual factors: Heterogeneity could partially be explained by diagnostic system, sample size and geographical location. Age of BD onset occurred earlier in patients with comorbid ADHD (3.96 years; 95 % CI: 2.65-5.26, p < 0.001). Cultural and methodological differences deserve attention for evaluating diagnostic criteria and clinicians should be aware of the high comorbidity rates to prevent misdiagnosis and provide optimal care for both disorders.

A Naturalistic Study of Youth Referred to a Tertiary Care Facility for Acute Hypomanic or Manic Episode

Background: Bipolar Disorders (BD) in youth are a heterogeneous condition with different phenomenology, patterns of comorbidity and outcomes. Our aim was to explore the effects of gender; age at onset (prepubertal- vs. adolescent-onset) of BD; and elements associated with attention deficit hyperactivity disorder (ADHD) and Substance Use Disorder (SUD) comorbidities, severe suicidal ideation or attempts, and poorer response to pharmacological treatments. Method: 117 youth (69 males and 57 females, age range 7 to 18 years, mean age 14.5 ± 2.6 years) consecutively referred for (hypo)manic episodes according to the Diagnostic and Statistical Manual of Mental Disorders, 54th ed (DSM 5) were included. Results: Gender differences were not evident for any of the selected features. Prepubertal-onset BD was associated with higher rates of ADHD and externalizing disorders. SUD was higher in adolescent-onset BD and was associated with externalizing comorbidities and lower response to treatments. None of the selected measures differentiated patients with or without suicidality. At a 6-month follow up, 51.3% of the patients were responders to treatments, without difference between those receiving and not receiving a psychotherapy. Clinical severity at baseline and comorbidity with Conduct Disorder (CD) and SUD were associated with poorer response. Logistic regression indicated that baseline severity and number of externalizing disorders were associated with a poorer outcome. Conclusions: Disentangling broader clinical conditions in more specific phenotypes can help timely and focused preventative and therapeutic interventions.

Developing and Validating a Definition of Impulsive/Reactive Aggression in Youth

The goal of this study is to develop a rational data-driven definition of impulsive/reactive aggression and establish distinctions between impulsive/reactive aggression and other common childhood problems. This is a secondary analysis of data from Assessing Bipolar: A Community Academic Blend (ABACAB; N = 636, ages 5-18), Stanley Medical Research Institute N = 392, ages 5-17), and the Longitudinal Assessment of Manic Symptoms (LAMS; N = 679, ages 6-12) studies, which recruited youths seeking outpatient mental health services in academic medical centers and community clinics. Following Jensen et al.'s (2007) procedure, 3 judges independently rated items from several widely used scales in terms of assessing impulsive/reactive aggression. Principal components analyses (PCA) modeled structure of the selected items supplemented by items related to mood symptoms, rule-breaking behavior, and hyperactivity/impulsivity to better define the boundaries between impulsive/reactive aggression and other common childhood symptoms. In the rational item selection process, there was good agreement among the 3 experts who rated items as characterizing impulsive/reactive aggression or not. PCA favored 5 dimension solutions in all 3 samples. Across all samples, PCA resulted in rule-breaking behavior, aggression-impulsive/reactive (AIR), mania, and depression dimensions; there was an additional hyperactive/impulsive dimension in the LAMS sample and a self-harm dimension in ABACAB and Stanley samples. The dimensions demonstrated good internal consistency; criterion validity coefficients also showed consistency across samples. This study is a step toward developing an empirically derived nosology of impulsive aggression/AIR. Findings support the validity of the AIR construct, which can be distinguished from manic and depressive symptoms as well as rule-breaking behavior.

Comorbidity of bipolar I disorder and conduct disorder: a familial risk analysis

OBJECTIVE

To investigate the association between pediatric bipolar I (BP-I) disorder and conduct disorder (CD) using familial risk analysis.

METHOD

We compared diagnoses in relatives of youth in four proband groups defined by the presence or absence of BP-I and CD: (1) probands with neither CD nor BP-I (probands: N = 550; relatives: N = 1656), (2) probands with CD and without BP-I (probands: N = 40; relatives: N = 127), (3) probands with BP-I and without CD (probands: N = 197; relatives: N = 579), and (4) probands with both CD and BP-I (probands: N = 176; relatives: N = 488). All subjects were evaluated with structured diagnostic interviews, and diagnoses of relatives were made blind to the diagnoses of probands.

RESULTS

Relatives of probands with BP-I disorder had high rates of BP-I, and relatives of probands with CD had high rates of CD irrespective of the comorbidity with the other disorder. Relatives of probands with the combined condition of CD and BP-I had high rates of the combined condition.

CONCLUSION

The finding of cosegregation between BP-I disorder and CD is consistent with the hypothesis that the combined condition represents a distinct subtype of either disorder.

Does the course of manic symptoms in pediatric bipolar disorder impact the course of conduct disorder? Findings from four prospective datasets

BACKGROUND

To assess whether the course of pediatric bipolar-I (BP-I) disorder impacts the course of conduct disorder (CD)/antisocial personality disorder (ASPD). We hypothesized that remission of manic symptoms in BP-I youth will be associated with remission of CD/ASPD.

METHODS

We used data from four longitudinal datasets of carefully characterized and comprehensively assessed youth with structured diagnostic interview based diagnoses of BP-I disorder and CD/ASPD assessed at baseline in childhood and at follow-up onto adolescent years. The baseline sample consisted of 240 subjects with full BP-I disorder. The average follow-up time was 6.6 ± 2.4 years.

RESULTS

Subjects with remitting BP-I disorder in adolescent years had a significantly lower one-year prevalence of CD or ASPD compared to those with persistent BP-I disorder (χ2 = 10.35, p = 0.001).

LIMITATIONS

Our inferences were derived from the examination of naturalistic longitudinal follow-up data and not results of a clinical trial.

CONCLUSIONS

Results indicate that remission of manic symptoms at the adolescent follow up in youth with BP-I disorder were associated with a significant decrease in rates of CD/ASPD. These results suggest that targeting manic symptoms in youth with BP-I disorder could mitigate the course of CD/ASPD in youth. Considering the high morbidity and disability associated CD/ASPD in youth and the limited treatment options available to address it, if replicated, these findings would have very important clinical and public health significance.

Efficacy and Safety of Risperidone and Quetiapine in Adolescents With Bipolar II Disorder Comorbid With Conduct Disorder

Although a frequent co-occurrence between bipolar disorder (BD) and conduct disorder (CD) in youth has been frequently reported, data about pharmacological management are scarce and focused on BD type I. Second generation antipsychotics are frequently used in clinical practice, but no comparative studies are available. The aim of this exploratory study was to compare efficacy and safety of risperidone and quetiapine in a sample of adolescents presenting a BD type II comorbid with CD. Twenty-two patients diagnosed with a structured interview according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (male/female ratio, 12/10; mean (SD) age 15.0 (1.4) years) were randomized in 2 treatment groups (quetiapine [n = 12] vs risperidone [n = 10]), treated with flexible doses, and followed up for 12 weeks. Efficacy measures assessed manic symptoms, aggression, anxiety, depression, global clinical severity, and impairment. Safety measures included body mass index, serum prolactin, extrapyramidal adverse effects, and electrocardiogram. At the end of the study, all patients improved in all efficacy measures. Both treatments showed similar efficacy in reducing manic symptoms and aggression. Quetiapine was more effective in improving anxiety and depressive symptoms. A change in body mass index was found, and in a post hoc analysis, it was significant only in the risperidone group. Prolactin significantly increased only in the risperidone group. In BD type II, CD comorbidity, quetiapine, or risperidone monotherapy may be effective and relatively safe, although the small sample size, the limited duration of the study, and the design (lack of a blind assessments and of a placebo group) make it difficult to draw definitive conclusions.

Can unipolar and bipolar pediatric major depression be differentiated from each other? A systematic review of cross-sectional studies examining differences in unipolar and bipolar depression

INTRODUCTION

While pediatric mania and depression can be distinguished from each other, differentiating between unipolar major depressive disorder (unipolar MDD) and bipolar major depression (bipolar MDD) poses unique clinical and therapeutic challenges. Our aim was to examine the current body of knowledge on whether unipolar MDD and bipolar MDD in youth could be distinguished from one another in terms of clinical features and correlates.

METHODS

A systematic literature search was conducted on studies assessing the clinical characteristics and correlates of unipolar MDD and bipolar MDD in youth.

RESULTS

Four scientific papers that met our priori inclusion and exclusion criteria were identified. These papers reported that bipolar MDD is distinct from unipolar MDD in its higher levels of depression severity, associated impairment, psychiatric co-morbidity with oppositional defiant disorder, conduct disorder and anxiety disorders, and family history of mood and disruptive behavior disorders in first-degree relatives.

LIMITATIONS

Though we examined a sizeable and diverse sample, we were only able to identify four cross sectional informative studies in our review. Therefore, our conclusions should be viewed as preliminary.

CONCLUSIONS

These findings can aid clinicians in differentiating the two forms of MDD in youth.

Can manic switches be predicted in pediatric major depression? A systematic literature review

BACKGROUND

The rate of switching from major depression to bipolar disorder is high in children. Predicting who is at risk for switching poses unique challenges and is of high clinical relevance. Our aim was to examine the existing scientific literature elucidating if certain clinical correlates predict ultimate bipolar switches in children initially presenting with a depressive episode.

METHODS

We conducted a systematic literature search of studies assessing the risk factors for bipolar switching in youth. In all, seven studies fit our a priori criteria and were thus included in our qualitative review.

RESULTS

Together, these papers found that manic switches in pediatric depression can be predicted by several risk factors, including positive family history of mood disorders, emotional and behavioral dysregulation, subthreshold mania, and psychosis.

LIMITATIONS

We identified only seven prospective informative studies for our review. The majority of subjects included in these studies were referred and Caucasian. Thus, the results may not generalize to other community samples and other ethnicities.

CONCLUSIONS

These findings can help alert clinicians of the risk of manic switches.

Cortical Volume Alterations in Conduct Disordered Adolescents with and without Bipolar Disorder

Background: There is increasing evidence that bipolar disorder (BD) and conduct disorder (CD) are co-occurring disorders. Magnetic resonance imaging has revealed differences in the structure and function of the frontal cortex in these disorders when studied separately; however, the impact of BD comorbidity on brain structure in adolescents with CD has not yet been examined. Method: We conducted an optimized voxel based morphometry (VBM) study of juvenile offenders with the following diagnoses: conduct disorder with comorbid bipolar disorder (CD-BD; n = 24), conduct disorder without bipolar disorder (CD; n = 24) and healthy controls (HC, n = 24). Participants were 13–17 years of age, in a residential treatment facility for repeat offenders. The three groups in this study were similar in age, gender, socioeconomic status and ethnicity. Results: We found CD-BD subjects had decreased volume relative to controls at the voxel level in the right medial prefrontal cortex (PFC). Using a Threshold-Free Cluster Enhancement (TFCE) technique, the CD-BD subjects had significantly decreased volumes of the right medial prefrontal cortex and portions of the superior and inferior frontal gyrus, anterior cingulate and temporal gyrus. The CD subjects did not have differences in brain volume compared to control subjects or CD-BD subjects. Conclusions: Our findings suggest the comorbidity between CD and BD is associated with neurobiological impact namely volumetric differences from healthy controls. Furthermore subjects with this comorbidity had poorer lifetime functioning, more mood and attentional dysfunction, and more medication exposure than subjects with CD who were not BD.

Quetiapine monotherapy in adolescents with bipolar disorder comorbid with conduct disorder

Bipolar Disorders (BD) are often comorbid with disruptive behaviour disorders (DBDs) (oppositional-defiant disorder or conduct disorder), with negative implications on treatment strategy and outcome. The aim of this study was to assess the efficacy of quetiapine monotherapy in adolescents with BD comorbid with conduct disorder (CD). A consecutive series of 40 adolescents (24 males and 16 females, age range 12-18 years, mean age 14.9 ± 2.0 years), diagnosed with a clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]) according to American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) criteria were included. All the patients were treated with quetiapine monotherapy (mean final dose 258 ± 124 mg/day, range 100-600 mg/day). At the end-point (3 months), 22 patients (55.0%) were responders (Clinical Global Impressions-Improvement [CGI-I] score of 1 or 2 and CGI-Severity [CGI-S] ≤ 3 and improvement of at least 30% Children's Global Assessment Scale [C-GAS] during 3 consecutive months). Both CGI-S and C-GAS significantly improved (p<0.0001). Nine out of the 16 patients with suicidality (56.3%) had a reduction in this severe symptom during the follow-up. Nonresponders were more frequently males, and more frequently had an attention-deficit/hyperactivity disorder (ADHD) comorbidity. Eight patients (20.0%) experienced moderate to severe sedation and eight (20.0%) experienced increased appetite and weight gain. In these severely impaired adolescents, quetiapine monotherapy was well tolerated and effective in>50% of the patients.

Higher risk of developing mood disorders among adolescents with comorbidity of attention deficit hyperactivity disorder and disruptive behavior disorder: a nationwide prospective study

Attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) are frequently comorbid. Previous studies suggested that the comorbidity of CD and ODD in ADHD may increase the risk of a further development of mood disorder, but most studies had a small sample size. Using a population-based prospective study design, a large sample composed of 1277 adolescents with ADHD-alone, 46 with ADHD + ODD, 87 with ADHD + CD, and 5640 age/gender-matched controls were enrolled in 2003. These cases were followed to 2010 to identify the cases developing unipolar depressive disorder and bipolar disorder. ADHD + CD groups exhibited a higher prevalence of unipolar depressive disorder (23.0% vs. 13.0% vs. 8.7% vs. 0.7%, p < 0.001) and bipolar disorder (3.4% vs. 2.2% vs. 1.3% vs. 0.2%, p < 0.001) than ADHD + ODD group, ADHD-alone group, and control group. Adolescents with ADHD + CD, those with ADHD + ODD, and those with ADHD-alone had a higher likelihood of developing unipolar depressive disorder (hazard ratio [HR]: 44.34, 95% confidence interval [CI]: 23.95-71.36; HR: 18.76, 95%CI: 7.87-44.71; HR: 13.01, 95%CI: 8.99-18.82) and bipolar disorder (HR: 14.39, 95%CI: 4.00-51.80; HR: 8.32, 95%CI: 1.06-65.32; HR: 5.24, 95%CI: 2.44-11.24) than the controls. Adolescents with ADHD had elevated risks of unipolar depression and bipolar disorder in their later life, and especially, those with ADHD and comorbidity of CD or ODD exhibited the highest risk. Further study would be required to evaluate whether prompt intervention for ADHD and disruptive behavior problems would decrease the risk of developing mood disorder.

Further understanding of the comorbidity between Attention-Deficit/Hyperactivity Disorder and bipolar disorder in adults: an MRI study of cortical thickness

Although Attention-Deficit/Hyperactivity Disorder (ADHD) and Bipolar Disorder (BPD) frequently co-occur and represent a particularly morbid clinical form of both disorders, neuroimaging research addressing this comorbidity is scarce. Our aim was to evaluate cortical thickness in ADHD and BPD, testing the hypothesis that comorbid subjects (ADHD+BPD) would have neuroanatomical correlates of both disorders. Magnetic Resonance Imaging (MRI) findings were compared between 31 adults with ADHD+BPD, 18 with BPD, 26 with ADHD, and 23 healthy controls. Cortical thickness analysis of regions of interest was estimated as a function of ADHD and BPD status, using linear regression models. BPD was associated with significantly thicker cortices in 13 regions, independently of ADHD status and ADHD was associated with significantly thinner neocortical gray matter in 28 regions, independent of BPD. In the comorbid state of ADHD plus BPD, the profile of cortical abnormalities consisted of structures that are altered in both disorders individually. Results support the hypothesis that ADHD and BPD independently contribute to cortical thickness alterations of selective and distinct brain structures, and that the comorbid state represents a combinatory effect of the two. Attention to comorbidity is necessary to help clarify the heterogeneous neuroanatomy of both BPD and ADHD.

Assessing disordered thoughts in preschoolers with dysregulated mood

There is rising interest in identifying precursors to bipolar disorder symptoms, including thought disorder. Thought disorder is identified in adults through self-report and in school-aged children through parent report and child story-telling. This study is an exploration to determine if preschoolers with mood dysregulation have evidence of disordered thoughts using a story-stem completion method. Participants included two groups of 3.5-6 year-old children: 20 with mood dysregulation including manic symptoms and 11 typically developing comparison children. Children were administered story completion narratives including one story where the child character accidentally cuts him/herself while pretending to cook. The children were asked to complete the stories and their responses were analyzed for atypical themes consistent with disordered thoughts such as violence or bizarreness outside of the story or props coming to life. Thirty-five percentage of symptomatic preschoolers versus 0% of typically developing preschoolers ascribed independent actions to inanimate props (p = 0.03). Eighty percentage of symptomatic preschoolers versus 9% of typically developing preschoolers utilized props in a violent or bizarre manner outside the central story (p < 0.001). Preschool children with symptoms of dysregulated mood express themes related to the unusual use of story props which may indicate disordered thoughts. This preschool expression of dysregulated mood appears similar to and possibly continuous with school-age and adult versions of bipolar disorder.

Risk for switch from unipolar to bipolar disorder in youth with ADHD: a long term prospective controlled study

BACKGROUND

To investigate whether ADHD is a risk factor for switches from unipolar to bipolar disorder over time.

METHODS

Data from two large controlled longitudinal family studies of boys and girls with and without ADHD and their siblings were used. Subjects (n=168) were followed prospectively and blindly over an average follow-up period of 7 years. Comparisons were made between youth with unipolar major depression who did and did not switch to full or subthreshold BP-I disorder at the follow-up assessment. Subjects were assessed at baseline and follow-up on multiple domains of functioning. Positive family history of parental psychiatric disorders was also compared between groups.

RESULTS

ADHD was associated with a significantly higher risk for switches from unipolar to bipolar disorder (28% versus 6%; z=2.80, p=0.005). In subjects with ADHD, switches from unipolar to bipolar disorder were predicted by baseline comorbid conduct disorder, school behavior problems, and a positive family history of parental mood disorder.

LIMITATIONS

Psychosis was an exclusionary criterion in the original ascertainment of the studies of ADHD probands, so we were unable to test this as a predictor of switching to BPD.

CONCLUSIONS

ADHD is a risk factor for switches from unipolar to bipolar disorder, and switches could be predicted by the presence of baseline conduct disorder, school behavior problems, and a positive family history of a mood disorder in a parent. These characteristics can aid clinicians in their treatment of youth with MDD.

[Nature and severity of oppositional defiant disorder and conduct disorder as they occur together or separately in children]

OBJECTIVE

Co-occurring oppositional defiant disorder and conduct disorder symptoms are particularly common, which could be related to the greater severity (number and nature of symptoms) of each disorder. Our study aims to determine if oppositional defiant disorder and conduct disorder symptoms vary when they occur together or separately in children.

METHOD

Our study was conducted with 406 children (aged 6 to 13 years) divided in 4 groups (oppositional disorder only, conduct disorder only, oppositional disorder and conduct disorder, control) with no age or sex difference. Structured diagnostic interviews conducted with one parent and each child separately led to assessing the average number of symptoms for each disorder as well as the onset frequency of each symptom.

RESULTS

When occurring together, oppositional disorder and conduct disorder appear more severe than when they occur separately, considering the number and nature of symptoms shown. Further, children with an oppositional disorder only or a conduct disorder only also have more frequent symptoms of the other disorder, compared with children in the control group.

CONCLUSION

These results suggest taking into account, at the time of assessment and potential intervention, the presence of both disorders.

Genetics of attention-deficit hyperactivity disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD) is a clinically and genetically heterogeneous syndrome which is comorbid with childhood conduct disorder, alcoholism, substance abuse, dis-social personality disorder, and affective disorders. A small but consistent overlap with autistic symptoms has also been established. Twin and family studies of ADHD show a substantial genetic heritability with little or no family environmental effect. Linkage and association studies have conclusively implicated the dopamine transporter gene (DAT1). DAT1 has also been confirmed as being associated with bipolar disorder. Remarkably, and for the first time in psychiatry, genetic markers at the DAT1 locus appear to be able to predict clinical heterogeneity because the non-conduct disordered subgroup of ADHD is associated with DAT1 whereas other subgroups do not appear to be associated. The second most well replicated susceptibility gene encodes the DRD4 dopamine receptor and many other dopamine related genes appear to be implicated. It is becoming increasingly clear that genes causing bipolar mania overlap with genes for a subtype of ADHD. The key to understanding the genetics of ADHD is to accept very considerable heterogeneity with different genes having effects in different families and in different individuals. It is too early to interpret the new wave of genome-wide association and copy number variant studies but preliminary data support the overlap with affective disorder genes and also with CNS connectivity genes likely to be involved in autism and affective disorders.

The Child Behavior Checklist-Pediatric Bipolar Disorder profile predicts a subsequent diagnosis of bipolar disorder and associated impairments in ADHD youth growing up: a longitudinal analysis

OBJECTIVE

To examine the predictive utility of the Child Behavior Checklist-Pediatric Bipolar Disorder (CBCL-PBD) profile to help identify children at risk for bipolar disorder.

METHOD

Subjects were ascertained from 2 identically designed longitudinal case-control family studies of subjects (males and females aged 6-18 years) with DSM-III-R attention-deficit/hyperactivity disorder (ADHD). Based on data from the baseline assessment, ADHD subjects without a lifetime diagnosis of bipolar disorder were stratified by the presence (CBCL-PBD positive, N=28) or absence (CBCL-PBD negative, N=176) of a CBCL-PBD score > or = 210 (total of attention, aggression, and anxious/depressed subscales). Subjects were comprehensively assessed at follow-up with structured psychiatric interviews. Data were collected from April 1988 to February 2003.

RESULTS

Over a mean follow-up period of 7.4 years, a positive CBCL-PBD score predicted subsequent diagnoses of bipolar disorder, major depressive disorder, and conduct disorder, as well as impaired psychosocial functioning and higher risk for psychiatric hospitalization.

CONCLUSION

This work suggests that a positive CBCL-PBD score based on elevations on the attention problems, aggressive behavior, and anxious/depressed subscales predicts subsequent pediatric bipolar disorder and associated syndrome-congruent impairments. If confirmed in other studies, the CBCL-PBD score has the potential to help identify children at high risk to develop bipolar disorder.

Clinical implications of current findings in neurodevelopment

Research in the last decade has advanced our knowledge about biological factors underlying neurodevelopmental processes in childhood. Genetic research has gone beyond mapping the human genome to identifying epigenetic factors and explicating gene-environment interactions. Biological markers of vulnerability to specific disorders have been identified. The functions of and interactions between neuroanatomic regions have been illuminated by new imaging and other noninvasive techniques, such as EEG, event-related potentials, and functional magnetic resonance imaging, that allow us to link earliest signs of disorders to neurological changes. This article provides an overview of current findings in neurodevelopment, and discusses diagnostic factors, prevention and intervention, and clinical implications.

Parsing the familiality of oppositional defiant disorder from that of conduct disorder: a familial risk analysis

BACKGROUND

Family risk analysis can provide an improved understanding of the association between attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), attending to the comorbidity with conduct disorder (CD).

METHODS

We compared rates of psychiatric disorders in relatives of 78 control probands without ODD and CD (Control, N=265), relatives of 10 control probands with ODD and without CD (ODD, N=37), relatives of 19 ADHD probands without ODD and CD (ADHD, N=71), relatives of 38 ADHD probands with ODD and without CD (ADHD+ODD, N=130), and relatives of 50 ADHD probands with ODD and CD (ADHD+ODD+CD, N=170).

RESULTS

Rates of ADHD were significantly higher in all three ADHD groups compared to the Control group, while rates of ODD were significantly higher in all three ODD groups compared to the Control group. Evidence for co-segregation was found in the ADHD+ODD group. Rates of mood disorders, anxiety disorders, and addictions in the relatives were significantly elevated only in the ADHD+ODD+CD group.

CONCLUSIONS

ADHD and ODD are familial disorders, and ADHD plus ODD outside the context of CD may mark a familial subtype of ADHD. ODD and CD confer different familial risks, providing further support for the hypothesis that ODD and CD are separate disorders.

Review of the literature regarding early intervention for children and adolescents aged 0-15 experiencing a first-episode psychiatric disturbance

AIM

The purpose of this review is to report on existing literature regarding children and adolescents younger than 16 years of age experiencing a first-episode psychiatric disturbance. Rather than providing a comprehensive list of service implications, this paper identifies some of the gaps in knowledge and practice to encourage ongoing analysis regarding better practices for early intervention for children and adolescents experiencing a first-episode psychiatric disturbance.

METHODS

A search was conducted to identify key evidence-based literature published from 1985 to 2007 discussing various aspects of child and youth mental health in Canada, the USA, the UK, Australia and New Zealand. The review also included 'grey' literature. Categories of information include diagnoses, pharmacological and non-pharmacological treatment, prevalence, environmental and other risk factors, and demographic variables.

RESULTS

Understanding first-episode psychiatric disturbance for patients under the age of 16 years is limited because of a scarcity of controlled studies focusing on this population. Programme evaluations are sparse, perhaps because of the small number of specialized units servicing this population. It may be helpful to enlist early intervention psychosis programmes that have been successful in assisting young people aged 16-24 in the development of better practices and care outcomes for younger age groups.

CONCLUSIONS

The authors highlight information that has the potential to assist in optimizing care for those youth younger than 16 years experiencing or exhibiting signs of a first-episode psychiatric disturbance.

Bipolar disorder--methodological problems and future perspectives

Since its “rebirth” in 1966, bipolar disorder (BPD) has rapidly come to occupy a central position in the research and treatment of mood disorders. Compared with major depressive disorder (MDD), BPD is a more serious condition, characterized by much more frequent recurrence, more complex comorbidity, and higher mortality. One major problem is the lack of valid definitions in adult and in child psychiatry; the current definitions are unsatisfactory, and heavily favor an overdiagnosis of MDD. Biological research is partially based on those definitions, which have a short half-life. An additional, dimensional, approach, quantifying hypomania, depression, and anxiety by self-assessment and symptom checklists is recommended, A further, related problem is the early recognition of the onset of BPD, especially in adolescence, and the identification of correlates in childhood. Early and timely diagnosis of BPD is necessary to enable prompt intervention and secondary prevention of the disorder. The paper describes the current status and future directions of developing clinical concepts of bipolarity

Towards further understanding of the co-morbidity between attention deficit hyperactivity disorder and bipolar disorder: a MRI study of brain volumes

BACKGROUND

Although attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) co-occur frequently and represent a particularly morbid clinical form of both disorders, neuroimaging research addressing this co-morbidity is scarce. Our aim was to evaluate the morphometric magnetic resonance imaging (MRI) underpinnings of the co-morbidity of ADHD with BPD, testing the hypothesis that subjects with this co-morbidity would have neuroanatomical correlates of both disorders.

METHOD

Morphometric MRI findings were compared between 31 adults with ADHD and BPD and with those of 18 with BPD, 26 with ADHD, and 23 healthy controls. The volumes (cm(3)) of our regions of interest (ROIs) were estimated as a function of ADHD status, BPD status, age, sex, and omnibus brain volume using linear regression models.

RESULTS

When BPD was associated with a significantly smaller orbital prefrontal cortex and larger right thalamus, this pattern was found in co-morbid subjects with ADHD plus BPD. Likewise, when ADHD was associated with significantly less neocortical gray matter, less overall frontal lobe and superior prefrontal cortex volumes, a smaller right anterior cingulate cortex and less cerebellar gray matter, so did co-morbid ADHD plus BPD subjects.

CONCLUSIONS

Our results support the hypothesis that ADHD and BPD independently contribute to volumetric alterations of selective and distinct brain structures. In the co-morbid state of ADHD plus BPD, the profile of brain volumetric abnormalities consists of structures that are altered in both disorders individually. Attention to co-morbidity is necessary to help clarify the heterogeneous neuroanatomy of both BPD and ADHD.

The long-term longitudinal course of oppositional defiant disorder and conduct disorder in ADHD boys: findings from a controlled 10-year prospective longitudinal follow-up study

BACKGROUND

A better understanding of the long-term scope and impact of the co-morbidity with oppositional defiant disorder (ODD) and conduct disorder (CD) in attention deficit hyperactivity disorder (ADHD) youth has important clinical and public health implications.

METHOD

Subjects were assessed blindly at baseline (mean age=10.7 years), 1-year (mean age=11.9 years), 4-year (mean age=14.7 years) and 10-year follow-up (mean age=21.7 years). The subjects' lifetime diagnostic status of ADHD, ODD and CD by the 4-year follow-up were used to define four groups (Controls, ADHD, ADHD plus ODD, and ADHD plus ODD and CD). Diagnostic outcomes at the 10-year follow-up were considered positive if full criteria were met any time after the 4-year assessment (interval diagnosis). Outcomes were examined using a Kaplan-Meier survival function (persistence of ODD), logistic regression (for binary outcomes) and negative binomial regression (for count outcomes) controlling for age.

RESULTS

ODD persisted in a substantial minority of subjects at the 10-year follow-up. Independent of co-morbid CD, ODD was associated with major depression in the interval between the 4-year and the 10-year follow-up. Although ODD significantly increased the risk for CD and antisocial personality disorder, CD conferred a much larger risk for these outcomes. Furthermore, only CD was associated with significantly increased risk for psychoactive substance use disorders, smoking, and bipolar disorder.

CONCLUSIONS

These longitudinal findings support and extend previously reported findings from this sample at the 4-year follow-up indicating that ODD and CD follow a divergent course. They also support previous findings that ODD heralds a compromised outcome for ADHD youth grown up independently of the co-morbidity with CD.

New insights into the comorbidity between ADHD and major depression in adolescent and young adult females

OBJECTIVE

The main aim of this study was to evaluate the association between attention-deficit/hyperactivity disorder (ADHD) and major depression (MD) in adolescent and young adult females.

METHOD

Subjects were females with (n = 140) and without (n = 122) ADHD ascertained from pediatric and psychiatric settings. Subjects were followed prospectively for 5 years into adolescence and young adulthood and reassessed in multiple nonoverlapping domains including psychiatric, cognitive, interpersonal, family, and educational functioning.

RESULTS

Females with ADHD had a 2.5 times higher risk for MD at adolescent follow-up compared with control females, adjusting for psychiatric comorbidity. MD in females with ADHD was associated with an earlier age at onset, greater than twice the duration, more severe depression-associated impairment, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization than MD in control girls. Parental MD and proband mania were significant predictors of MD among females with ADHD, independently of other predictors.

CONCLUSIONS

MD emerging in the context of ADHD in females is an impairing and severe comorbidity worthy of further clinical and scientific considerations.

[Characteristics associated with conduct disorder, oppositional defiant disorder and comorbidity]

The purpose of the study is to determine whether pattern of association with psychological, social and family correlates are similar for oppositional defiant disorder (ODD), conduct disorder (CD), and ODD + CD. Participants were 336 boys and girls (age range from 6 to 13 years) in treatment for disruptive behaviour disorders including 123 children with ODD, 39 with CD "only", and 174 with ODD + CD. Results showed that parent's antisocial personality and poor supervision characterized children with CD whereas children with ODD presented with more attention deficit/hyperactivity symptoms and inconsistent discipline. All these correlates characterized children with ODD + CD. These results suggest the importance of taking into account these differences between groups in children treatment.

Differences between prepubertal- versus adolescent- onset bipolar disorder in a Spanish clinical sample

OBJECTIVE

To examine patients attended and diagnosed with bipolar disorder (BD) at a child and adolescent psychiatry service; to record age of diagnosis and age of onset, and to study clinical differences between prepubertal and adolescent onset groups.

METHODS

All patients currently attended for BD type I, type II or non specified BD were reviewed and divided into two age groups: prepubertal onset (beginning before age 13) and adolescent onset (beginning at or above age 13).

RESULTS

The sample were 43 patients with BD. Fourteen (32.6%) with prepubertal onset and 29 (67.4%) with adolescent onset. Time between onset of symptoms and diagnosis was longer in the prepubertal onset group (1.2 years versus 0.8 years respectively, P = .05). Patients with prepubertal onset BD more frequently presented previous symptoms such as irritability and conduct problems and had a higher rate of comorbidity (more frequently attention-deficit/hyperactivity disorder-ADHD). The adolescent onset group more often presented psychotic symptoms.

CONCLUSION

The clinical characteristics of patients with bipolar disorder differ according to whether onset is prepubertal or adolescent.

Aggression, hostility, and irritability in children at risk for bipolar disorder

OBJECTIVES

To assess aggression, irritability and hostility in children at risk for bipolar disorder (BP).

METHODS

Using the parent and the child versions of the Children's Hostility Inventory (CHI), we assessed aggression, hostility, and irritability in 300 offspring aged 6-18 years old of BP parents and 169 children of community controls.

RESULTS

Children of BP parents have significantly higher scores on the total CHI and its subscales than do children of control parents. After adjusting for demographic variables, both parents' non-BP psychopathology, child psychopathology, and within-family correlations, three factors remain significant: total CHI by parent rating, irritability subscale by parent rating, and irritability by child self-report. The hostility subscale by parent rating became a trend.

CONCLUSIONS

Children of BP parents score higher on ratings of hostility and irritability than children of community control parents, independent of child psychopathology and non-BP parental psychopathology. Follow-up of these children to evaluate whether these symptoms are markers for the development of BP or mood disorders is warranted.

Are behavioral problems in childhood and adolescence associated with bipolar disorder in early adulthood?

Several recent studies have found an association between conduct problems and bipolar disorder in adolescents. However, prospective studies are rare and most do not apply multivariable analysis strategies to control for important variables (e.g. socio-demographics). The aim of this study was to test the association between certain conduct problems and bipolar disorders. The sample consisted of 591 adolescents (male and female) representative for 2,600 persons from the Canton of Zurich in Switzerland. Data were prospectively collected through an interviewing procedure, with the first screening taking place at the age of 19-20. The incidence rate was computed using sampling weights, and risk factors of bipolar II disorder were estimated using a multivariable logistic regression model. The 9-year incidence rate of bipolar II disorder in the canton of Zurich was 8.4% (n = 65). Adolescents and children showing behavior such as repeated running away from home and physical fighting were 2.6-3.5 times more likely to experience a bipolar II disorder than those with no indication of conduct problems. Sensitivity analysis showed that the conduct problems were not the result of low socio-economic status.

Treating common psychiatric disorders associated with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) often occurs along with other psychiatric disorders, with estimated comorbidity rates of 50--90%. Comorbidity greatly influences presentation, diagnosis and prognosis, complicates treatment and significantly increases the morbidity and disease burden of ADHD. Commonly co-occurring psychiatric disorders are disruptive behavior disorder, anxiety, depression, bipolar disorder and substance use disorders. This article provides a brief review of effective strategies for treating the most common psychiatric disorders associated with ADHD. This paper also discusses knowledge gaps in the understanding of treatment of comorbid disorders associated with ADHD, and directions for future research.

Childhood antecedent disorders to bipolar disorder in adults: a controlled study

OBJECTIVE

The aim of the study was to examine antecedent childhood psychiatric disorders in adult patients with bipolar disorder.

METHOD

Using structured diagnostic interviews, childhood psychiatric diagnoses of 83 referred patients with diagnosed DSM-IV bipolar disorder were compared to those of 308 adults without mood disorders.

RESULTS

Patients with bipolar disorder had significantly higher rates of childhood disruptive behavior disorders (ADHD, oppositional-defiant disorder, and conduct disorder), childhood anxiety disorders (separation anxiety and overanxious disorder), and enuresis, compared to patients without mood disorders. The presence of these childhood disorders was associated with an earlier age of onset of bipolar illness.

LIMITATIONS

The retrospective nature of the study may have affected both the rates of disorders recalled, as well as the ages of onset of disorders. Different referral sources for bipolar and comparison participants may have also impacted findings.

CONCLUSIONS

Bipolar disorder in adults is frequently preceded by childhood disruptive behavior and anxiety disorders. These childhood disorders may be important markers of risk for adult bipolar disorder.

Prevention of Pediatric Bipolar Disorder: Integration of Neurobiological and Psychosocial Processes

Bipolar disorder (BD) is a prevalent condition in the United States that typically begins before the age of 18 years and is being increasingly recognized in children and adolescents. Despite great efforts in discovering more effective treatments for BD, it remains a difficult-to-treat condition with high morbidity and mortality. Therefore, it appears prudent to focus energies into developing interventions designed to prevent individuals from ever fully developing BD. Such interventions early in the development of the illness might prevent inappropriate interventions that may worsen or hasten development of BD, delay the onset of first manic episode, and/or prevent development of full BD. Studies of populations at high-risk for BD development have indicated that children with strong family histories of BD, who are themselves experiencing symptoms of attention-deficit/hyperactive disorder (ADHD) and/or depression or have early mood dysregulation, may be experiencing prodromal states of BD. Understanding the neurobiological and genetic underpinnings that create risk for BD development would help with more accurate identification of this prodromal population, which could then lead to suitable preventative interventions. Such interventions could be pharmacologic or psychosocial in nature. Reductions in stress and increases in coping abilities through psychosocial interventions could decrease the chance of a future manic episode. Similarly, psychotropic medications may decrease negative sequelae of stress and have potential for neuroprotective and neurogenic effects that may contribute to prevention of fully expressed BD. Further research into the biologic and environmental mechanisms of BD development as well as controlled early intervention studies are needed to ameliorate this significant public health problem.

Risperidone for the treatment of affective symptoms in children with disruptive behavior disorder: a post hoc analysis of data from a 6-week, multicenter, randomized, double-blind, parallel-arm study

BACKGROUND

Despite the increasing recognition of bipolar disorder in childhood, there have been no controlled, randomized clinical trials of atypical antipsychotics in this population. Preliminary data from open-label trials in children suggest that these agents might be effective in treating pediatric bipolar disorder, however.

OBJECTIVE

The purpose of this post hoc analysis of data from Aman et al was to determine the effects of risperidone in the management of affective symptoms in children with disruptive behavioral disorders (DBDs).

METHODS

This report presents a secondary analysis of a previously reported 6-week, multicenter, double-blind, randomized, parallel-arm trial comparing 6 weeks of administration of risperidone (flexible dosing starting at 0.02 mg . kg .1 . d(-1) and titrated up to 0.06 mg kg(-1) d(-1)) versus placebo in children with DBDs and subaverage intelligence. Twenty-four candidate affective symptoms of mania and depression were extracted from the 64-item Nisonger Child Behavior Rating Form (NCBRF). To define independent dimensions of mood-disorder psychopathology, these 24 symptoms were assigned 1 of 3 independent dimensions (symptoms of mania) based on loading: explosive irritability; agitated, expansive, grandiose; and depression. A fourth, nonaffective independent dimension encompassed a combination of nonaffec tive symptoms on the NCBRF Conduct Problem subscale. To assess treatment effect, each independent dimension was assigned a score derived from the sum of the symptoms that loaded on that dimension at weeks 2, 4, and 6 of study drug administration.

RESULTS

A total of 110 patients were included in the independent-dimension analysis (89 boys, 21 girls; risperidone, 49 patients; placebo, 61 patients; mean [SD] age, 8.6 [2.3] and 8.1 [2.4] years in the risperidone and placebo groups, respectively; mean [SD] weight, 33.9 [12.8] and 32.1 [12.0] kg in the risperidone and placebo groups, respectively). The treatment-effect analysis found that the mean scores of all 3 independent dimensions were significantly reduced with risperidone compared with placebo at weeks 2, 4, and 6 (all, P <or= 0.03). The effect sizes of improvement in these factors ranXged from 0.44 to 0.95 at end point.

CONCLUSIONS

The results of this post hoc analysis of affective symptoms of DBDs using data from a previously published randomized, double-blind clinical comparison of risperidone and placebo in the treatment of children with DBDs and subaverage intelligence suggest that risperidone was effective in treating the factors of explosive irritability; agitated, expansive, grandiose; and depression.

Pharmacological aspects of the treatment of conduct disorder in children and adolescents

In recent years, the rates of psychosocial disorders in children and adolescents have increased, with behavioural manifestations of conduct disorder being one of the most common reasons for referrals to community psychiatrists. Childhood conduct problems are associated with a variety of psychiatric disorders in adult life that extend beyond antisocial behaviour. An increased awareness of the costs of conduct disorder to individuals, families and society has led to advancements in the pharmacological and nonpharmacological therapeutic modalities for this disorder. Despite this, patients with conduct disorder are difficult to treat as the patterns of maladaptive behaviours they exhibit are diverse and can vary as a function of age and sex. A multidisciplinary approach to the treatment of conduct disorder, which includes behavioural parent training, interpersonal skills training, family therapy and the use of psychotropic agents targeted at a particular cluster of symptoms, can increase the overall effectiveness of each of the applied interventions. Aggression, hyperactivity, impulsivity and mood symptoms are the most sensitive proximal targets. Evidence suggests that antipsychotics, antidepressants, mood stabilisers, antiepileptic drugs, stimulants and adrenergic drugs can be well tolerated and effective therapeutic options for individuals with conduct disorder and comorbid psychiatric conditions. However, the most successful therapeutic outcomes are likely to be achieved by combining the current advances in psychopharmacology with behavioural and psychosocial interventions, aimed at modifying the excessive patterns of maladaptive behaviours observed in conduct disorder.

Olanzapine treatment in adolescents with severe conduct disorder

The most severe forms of conduct disorder (CD) are highly stable and disabling disorders, more likely to persist in time and to evolve into disruptive or antisocial behaviors. One crucial issue in the prognosis of these forms of CD is the high resistance to both non-pharmacological and pharmacological treatments, with antipsychotic drugs being frequently used in refractory cases. Aim of this study was: (1) to explore efficacy and tolerability of olanzapine treatment in adolescents with severe CD; (2) to identify predictors of olanzapine treatment outcome. This was a retrospective study, based on clinical records of the first 23 adolescents diagnosed as having a CD, diagnosed with a clinical interview (K-SADS), either pure or with comorbid diagnoses, and treated with olanzapine. All these patients did not respond satisfactorily to non-pharmacological intervention and to adequate dosages of mood stabilizers (lithium and/or valproate). The sample consisted of 16 males and seven females, 16 inpatients and seven outpatients (mean age 13.6 +/- 1.9 years, range 11-17.2 years), followed-up for a period ranging from 6 to 12 months (mean 8.8 +/- 2.7 months). Outcome measures included the Modified Overt Aggression Scale (MOAS), Clinical Global Impression-Improvement (CGI-I) and Children Global Assessment Scale (CGAS). During the follow-up, all patients were involved in non-pharmacological treatments (psychotherapy, family therapy, or day-hospital group treatments). Based on both an improvement of at least 50% at MOAS and a score 1 or 2 at CGI-I, 14 out of 23 patients (60.9%) were classified as responders at the end of the follow-up. Significant improvement at the last observation was found in MOAS (P < 0.001) and CGAS (P < 0.001) scores. Olanzapine dosage was 8 +/- 3.2 mg/day (range 5-20 mg/day). Mean weight gain at the end of the follow-up was 4.6 +/- 3 kg. The predictors of a positive treatment response was an impulsive-affective versus controlled-predatory type of aggression. Age at onset of CD and comorbid disorders did not affect treatment response. These preliminary findings suggest that olanzapine may improve behavior in adolescents with severe and treatment-refractory CD and impulsive aggression.

The psychopathology and treatment of bipolar disorder

In this chapter we review research on the diagnosis, course, etiology, and pharmacological and psychosocial treatment of bipolar disorder (BD). BD is a highly recurrent and severe illness, with high rates of suicidality and functional impairment. The disorder is heritable and appears to share susceptibility genes with schizophrenia. It is characterized by dysregulation in the dopamine and serotonin systems and by pathology in the brain systems involved in regulating emotion. Psychosocial stressors, notably life events and familial expressed emotion, significantly influence the course of the illness in the context of these vulnerabilities. Findings of randomized clinical trials indicate that psychosocial interventions enhance long-term outcomes when added to pharmacotherapy. Much remains to be clarified about the interactive contributions of genetic, neurobiological, and psychosocial factors to the course of the disorder, and the moderators and mediators of treatment effects.

Bipolar II and the bipolar spectrum

In studies made in the last decade, patients consulting doctors because of depression and anxiety have very often turned out to suffer from bipolar type II and similar conditions with alternating depression and hypomania/mania (the bipolar spectrum disorders - BP). Specifically, about every second patient seeking consultation because of depression has been shown to suffer from BP, mainly bipolar type II. BP is often concealed by other psychiatric conditions, e.g. recurrent depression, psychosis, anxiety, addiction, personality disorder, attention-deficit hyperactivity disorder and eating disorder. BP shows strong heredity. Relatives of patients with BP also have a high frequency of the psychiatric conditions just mentioned. Conversion ("switching") from recurrent unipolar depressions (recurrent UP) to BP is common in very long longitudinal studies (over decades). Mood-stabilizing medicines are recommended to a great extent in the treatment of BP, since anti-depressive medicines are often not effective and involve a substantial risk of inducing mood swings. Particularly in the long-term pharmacological treatment of depression in BP anti-depressive medicines may worsen the condition, e.g. inducing a symptom triad of dysphoria, irritability and insomnia: ACID (antidepressant-associated chronic irritable dysphoria).

Impulsive aggression with irritability and responsive to divalproex: a pediatric bipolar spectrum disorder phenotype?

BACKGROUND

The objective of this retrospective chart review was to evaluate the phenomenology and response to divalproex in a sub-population of children admitted to an inpatient setting with severe impairing symptoms of irritability and aggression. In addition, we examined whether the symptomatology of this group was consistent with a pediatric divalproex-responsive bipolar spectrum disorder.

METHODS

The charts of 46 child and adolescent patients with prominent impulsive aggression with irritability admitted to a crisis stabilization center were assessed retrospectively. Impulsive aggressive symptoms were assessed for admission and discharge severity by two clinicians using the Overt Aggression Scale (OAS) and the Anger-Hostility Subscale of the SCL-90 (SCL-A), with overall functioning changes assessed using the Children's Global Assessment Scale (C-GAS).

RESULTS

Statistically significant improvements were obtained for the group in the C-GAS, with significant decreases in the OAS and the SCL-A scores at discharge, following a maximal 14-day stay. No severe side effects were reported. All patients met the criteria for a potential pediatric bipolar phenotype.

LIMITATIONS

This was a retrospective study without randomization or a control group. Additionally, the non-blinded design may have biased the raters concerning the effectiveness of divalproex for impulsive aggression.

CONCLUSIONS

Our data are in line with divalproex response in children and adolescents with target symptoms of explosive temper and mood instability. Our data further suggest that such symptoms, coupled with impulsive aggression and irritability, as well as related manic symptoms, constitute a pediatric divalproex-responsive bipolar spectrum disorder.

Psychopathology in the offspring of parents with bipolar disorder: a controlled study

BACKGROUND

To examine the risk for psychopathology in offspring at risk for bipolar disorder and the course of psychiatric disorders in these youth.

METHODS

Using structured diagnostic interviews (Structured Clinical Interview for DSM-IV [SCID] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS]), psychiatric diagnoses of 117 nonreferred offspring of parents with diagnosed bipolar disorder were compared with those of 171 age- and gender-matched offspring of parents without bipolar disorder or major depression.

RESULTS

Compared with offspring of parents without mood disorders, high-risk youth had elevated rates of major depression and bipolar disorder, anxiety, and disruptive behavior disorders. High-risk offspring also had significantly more impaired Global Assessment of Functioning (GAF) scores, higher rates of psychiatric treatment, and higher rates of placement in special education classes. Disruptive behavior disorders, separation anxiety disorder, generalized anxiety disorder (GAD), social phobia, and depression tended to have their onset in early or middle childhood, whereas bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, and substance use disorder had onset most frequently in adolescence.

CONCLUSIONS

These findings support the hypothesis that offspring of parents with bipolar disorder are at significantly increased risk for developing a wide range of severe psychiatric disorders and accompanying dysfunction. Early disruptive behavior and anxiety disorders, as well as early-onset depression, may be useful markers of risk for subsequent bipolar disorder in high-risk samples.

Childhood antecedents to panic disorder in referred and nonreferred adults

OBJECTIVE

We used a recursive partitioning method to examine antecedent childhood anxiety disorders in large samples of referred and nonreferred subjects with and without panic disorder.

METHODS

Referred subjects included adults treated for panic disorder (n = 131) and comparison adults with neither major anxiety nor mood disorders (n = 61). The nonreferred adult group derived from an opportunistic sample originally ascertained through family studies of probands with and without attention-deficit/hyperactivity disorder (ADHD), yielding 58 adults with panic disorder and 587 who were free of major anxiety and mood disorders.

RESULTS

The majority of referred (65%) and nonreferred (52%) adults with panic disorder had antecedent childhood anxiety or disruptive behavior disorders. Classification and Regression Trees (CART) analysis showed that both separation anxiety disorder and overanxious disorder were independent predictors of subsequent panic disorder in both referred and nonreferred samples.

CONCLUSIONS

These results confirm and extend previously reported findings by documenting that childhood anxiety disorders are important antecedent risk factors for panic disorder, independently of referral bias.

Gilles de la Tourette's syndrome and its impact in the UK

Gilles de la Tourette's syndrome of chronic multiple motor and vocal tics is now acknowledged to be far more common than once thought, affecting up to 1% of schoolchildren with a wide range of severity. At the milder end of the spectrum the associated psychopathologies can in themselves impair social and educational functioning, in particular obsessive compulsive disorder and attention deficit hyperactivity disorder. Many patients with this condition are not being adequately served by health and education services in the UK. The epidemiology, clinical features, aetiological factors, and management of the syndrome are reviewed.

High rate of unrecognized bipolar mixed states among destitute Hispanic adolescents referred for "major depressive disorder"

OBJECTIVE

To ascertain the rate of bipolarity among adolescent Hispanic youths referred for the treatment of "major depressive disorder" (MDD) in a community mental health clinic (CMHC) in which the threshold for referral was moderate to severe impairment.

METHODS

The patients were 49 consecutively presenting Hispanic adolescents (33 girls and 16 boys with a range of 12-17 years), many of whom had histories of unruly, hostile and/or assaultive behavior; indeed, 1 out of 3 had been referred to the CMHC from the "First-Time Offenders Program." Upon evaluation at the CMHC triage unit, all were diagnosed as MDD rendered by a licensed paramedical mental health professional managing this unit. They were subsequently evaluated by a psychiatrist using the Structured Clinical Interview for DSM-IV.

RESULTS

Seventeen (51.5%) of the girls and 10 (62.5%) of the boys met the DSM-IV criteria for bipolar disorder. Among the bipolars, 44.4% were bipolar II and 55.6% bipolar I; 74.1%% had mixed states and 40.7% were psychotic (not mutually exclusive categories). Euphoric mania was virtually absent in this population.

LIMITATION

Data on social deviance was based on chart review. Nonetheless, given that a third had already entered the juvenile justice system upon referral validates the accuracy of characterizing this population as at least moderately impaired from the social deviance standpoint.

CONCLUSIONS

Hispanic adolescents referred with a presumptive diagnosis of MDD must be carefully assessed for the presence of occult bipolarity using a structured interview. Concurrent aggressiveness and depression should tip mental health clinicians towards bipolarity--especially mixed states. Such activated-hostile depressive (and/or manic) mixed states may in part underlie the social deviance in these patients. Given that these destitute youth are often simultaneously encountered in the juvenile justice system, undetected bipolarity among Hispanic adolescents initially regarded to have MDD represents a matter of grave public health importance. Appropriate training for mental health staff to recognize bipolar spectrum disorders in CMHCs should be mandated.

Co-existing disorders in ADHD -- implications for diagnosis and intervention

BACKGROUND

It is only recently that "comorbidity" in ADHD has come to the forefront as one of the most important aspects of the disorder. It is agreed that, often, these problems are at least as important as ADHD in contributing to the longer term outcome in the individual child.

OBJECTIVE

To provide the reader with basic information about clinics and treatment of "comorbidity" in ADHD.

METHOD

Review of the empirically based literature.

RESULTS

ADHD exists in a surprisingly high frequency together with a broad range of child neuropsychiatric disorders. This is accompanied with many still unresolved treatment problems.

CONCLUSION

It would not be appropriate to develop ADHD-services where clinicians would only have expertise in ADHD as such. Anyone working with children, adolescents and adults with ADHD would need to have training in general neuropsychiatry. Further research in this field is urgently needed.

Absence of gender differences in pediatric bipolar disorder: findings from a large sample of referred youth

BACKGROUND

Because little is known about gender differences in pediatric bipolar disorder, we evaluated whether gender moderates the expression of pediatric bipolar disorder in a large clinical sample.

METHODS

Subjects were consecutively referred youth aged 18 years or less who met full criteria for DSM-III-R bipolar disorder (BPD) (females, n=74; BD males, n=224). All subjects were assessed with a structured diagnostic interview and measures of psychosocial and family functioning.

RESULTS

Most of the bipolar subjects (91% of males, 70% of females) also had ADHD. Bipolar disorder was equally prevalent in both genders. Among females and males, severe irritability (83% and 80%, respectively), mixed presentation (87% and 84%, respectively), chronic course (84% and 77%, respectively) and prepubertal onset (78% and 93%, respectively) predominated the clinical picture. We found no meaningful differences between genders in the number of BPD symptoms, type of treatment for BPD (counseling, medication, hospitalization), severity of educational deficits, severity of family and interpersonal functioning or patterns of psychiatric comorbidity.

CONCLUSIONS

Because gender does not moderate the clinical expression of pediatric bipolar disorder, our data does not suggest that gender specific criteria for the disorder are warranted.