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

Sleep quality predicts future mood symptoms in adolescents with bipolar disorder

BACKGROUND

Poor sleep is prevalent in adolescents with bipolar disorder, precedes illness onset, and is associated with worse mood symptoms. We examined interrelationships between sleep quality and mood symptoms in adolescents with bipolar disorder, particularly effects of sleep quality on emergent mood symptoms.

METHODS

Adolescents with bipolar disorder participated in a two-year longitudinal treatment study. Sleep quality (Pittsburgh Sleep Quality Index, PSQI) was assessed quarterly during treatment (baseline, 3-, 6-, 9-, 12-month visits) and twice during follow-up (18-, 24-month visits). Mood symptoms (ALIFE Psychiatric Status Ratings) were retrospectively rated weekly by an independent clinician. Lag models tested whether sleep quality predicted next month's mood symptoms and whether mood symptoms predicted future sleep quality.

RESULTS

Adolescents with bipolar disorder had poor sleep quality. Sleep quality initially improved but remained stable thereafter. Worse sleep quality at 6-months predicted worse depression, hypomania, and suicidal ideation the following month. Sleep quality was worse for adolescents who had a suicide attempt during the study compared to those who did not and was worse preceding months with a suicide attempt compared to months without attempts. Alternatively, worse depression predicted worse future sleep quality at baseline, 3-, and 18-months and worse suicidal ideation predicted worse future sleep quality at baseline, 12-, and 18-months.

LIMITATIONS

Mood symptoms were rated retrospectively and the PSQI may not capture all dimensions of sleep important for mood symptoms.

CONCLUSIONS

Targeted evidence-based sleep treatment in adolescents with bipolar disorder may alleviate sleep problems and have additional benefits on mood symptoms and suicidality risk.

Losing control: Prefrontal emotion regulation relates to symptom severity and predicts treatment-related symptom change in adolescent girls with conduct disorder

BACKGROUND

Emotion regulation skills are linked to corticolimbic brain activity (e.g., dorsolateral prefrontal cortex (dlPFC) and limbic regions) and enable an individual to control their emotional experiences thus allowing healthy social functioning. Disruptions in emotion regulation skills are reported in neuropsychiatric disorders, including conduct disorder or oppositional defiant disorder (CD/ODD). Clinically recognized means to ameliorate emotion regulation deficits observed in CD/ODD include cognitive or dialectical behavioral skills therapy as implemented in the START-NOW program. However, the role of emotion regulation and its neural substrates in symptom severity and prognosis following treatment of adolescent CD/ODD has yet to be investigated.

METHODS

Cross-sectional data including fMRI responses during emotion regulation (N=114; average age=15years), repeated-measures assessments of symptom severity (pre-, post-treatment, long-term follow-up), and fMRI data collected prior to and following the START-NOW randomized controlled trial (n=44) for female adolescents with CD/ODD were analyzed using group comparisons and multiple regression.

RESULTS

First, behavioral and neural correlates of emotion regulation are disrupted in female adolescents with CD/ODD. Second, ODD symptom severity is negatively associated with dlPFC/precentral gyrus activity during regulation. Third, treatment-related symptom changes are predicted by pre-treatment ODD symptom severity and regulatory dlPFC/precentral activity. Additionally, pre-treatment dlPFC/precentral activity and ODD symptom severity predict long-term reductions in symptom severity following treatment for those participants that received the START NOW treatment.

CONCLUSION

Our findings demonstrate the important role that emotion regulation skills play in the characteristics of CD/ODD and show that regulatory dlPFC/precentral activity is positively associated with treatment response in female adolescents with CD/ODD.

Emotion dysregulation and psychopathological symptoms in non-clinical adolescents: The mediating role of boredom and social media use

BACKGROUND

Emotion dysregulation, boredom, and problematic social media use are well-known vulnerability factors for psychopathology during adolescence; nevertheless, the interplay between these factors remains underinvestigated in the literature. Therefore, the present cross-sectional study aimed to explore the mediating role of boredom and problematic social media use in the relations between emotion dysregulation and both internalizing and externalizing problems in a non-clinical group of Italian adolescents.

METHOD

721 students (64.6% girls; Mage = 15.49 years ± 1.82) were involved and completed self-report tools assessing emotion dysregulation, boredom, problematic social media use, and psychopathological symptoms. Path analysis was used to test whether boredom and problematic social media use mediated the relation between emotion dysregulation and psychopathology, distinguishing between internalizing and externalizing problems.

RESULTS

Path models showed that emotion dysregulation predicted both internalizing and externalizing problems, as well as boredom and problematic social media use. Importantly, boredom mediated the associations between emotion dysregulation and both psychopathological dimensions, while problematic social media use mediated only the relation with externalizing problems.

CONCLUSIONS

Our results highlight that the influence of emotion dysregulation on psychopathology can manifest through different paths, leading to specific symptomatology based on interactions between various variables. In particular, boredom seems to be a transdiagnostic factor for psychopathology in adolescence, whereas problematic social media use would be a dimension-specific factor. The practical implications of these findings are discussed.

Dialectical Behavior Therapy for Adolescents With Bipolar Disorder: A Randomized Clinical Trial

Importance

Early-onset bipolar disorder conveys substantial risk for suicide. No psychosocial intervention for this population expressly targets suicidal behavior.

Objective

To determine whether dialectical behavior therapy (DBT) for adolescents with bipolar spectrum disorder is more effective than standard of care (SOC) psychotherapy in decreasing suicide attempts over 1 year.

Design, Settings, and Participants

Adolescents aged 12 to 18 years diagnosed with bipolar spectrum disorder were recruited from a specialty outpatient psychiatric clinic between November 2014 and September 2019. Independent evaluators conducted quarterly assessments over 1 year with participants and parents. Data were analyzed from March 2021 to November 2022.

Interventions

Participants were randomly assigned to 1 year of DBT (36 sessions; n = 47) or SOC psychotherapy (schedule clinically determined; n = 53). All youth received medication management via a flexible algorithm.

Main Outcomes and Measures

Primary outcomes included suicide attempts over 1 year and mood symptoms and states (depression and hypomania/mania). Secondary analyses included moderation of DBT effects by history of suicide attempt and mediation through emotion dysregulation.

Results

Of 100 included participants, 85 (85%) were female, and the mean (SD) age was 16.1 (1.6) years. Participants were followed up over a mean (SD) of 47 (14) weeks. Both treatment groups demonstrated significant and similar improvement in mood symptoms and episodes over 1 year (standardized depression rating scale slope, -0.17; 95% CI, -0.31 to -0.03; standardized mania rating scale slope, -0.24; 95% CI, -0.34 to -0.14). DBT and SOC participants reported similar suicide attempt rates at intake as measured on the Adolescent Longitudinal Follow-Up Evaluation (ALIFE; mean [SD] attempts, 2.0 [4.5] vs 1.8 [3.9], respectively; P = .80). DBT participants reported slightly more suicide attempts at intake as measured on the Columbia-Suicide Severity Rating Scale Pediatric Version (C-SSRS; mean [SD] attempts, 1.4 [3.6] vs 0.6 [0.9]; P = .02). DBT participants reported significantly fewer suicide attempts over follow-up compared with SOC participants via the ALIFE (mean [SD] attempts per follow-up period, 0.2 [0.4] vs 1.1 [4.3], controlling for baseline attempts: P = .03) and the C-SSRS (mean [SD] attempts per follow-up period, 0.04 [0.2] vs 0.10 [0.3], controlling for baseline attempts; P = .03). DBT was significantly more effective than SOC psychotherapy at decreasing suicide attempts over 1 year (ALIFE: incidence rate ratio [IRR], 0.32; 95% CI, 0.11-0.96; C-SSRS: IRR, 0.13; 95% CI, 0.02-0.78). Decreased rate of suicide attempts in DBT was moderated by presence of lifetime history of suicide attempt and time (IRR, 0.23; 95% CI, 0.13-0.44) and mediated by improvement in emotion dysregulation (IRR, 0.61; 95% CI, 0.42-0.89), particularly for those with high baseline emotion dysregulation (standardized β, -0.59; 95% CI, -0.92 to -0.26).

Conclusions and Relevance

In this randomized clinical trial, DBT demonstrated efficacy in decreasing suicide attempts among the high-risk population of adolescents with bipolar spectrum disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT02003690.

Childhood emotional dysregulation paths for suicide-related behaviour engagement in adolescence

This study aimed at identifying the heterogeneous trajectories of emotional dysregulation across childhood and to study the relationship between specific trajectories and adolescent suicide-related behaviour (SRB). Data from the Millennium Cohort Study (N = 13,853 children; 49.07% female, M = 3.13 years at baseline, SD = 0.2) were used to identify the emotional dysregulation trajectories from 3 to 8 years old, using growth mixture modelling. Moreover, 1992 participants (52.86% female) from the initial sample were used to study the relationship between childhood emotional dysregulation trajectory and engagement in both self-harm and suicide attempt at age 17, using logistic regression. Some other time-invariant and proximal (adolescent) risk factors were incorporated into this analysis. Six emotional dysregulation trajectories were identified. Self-harm at age 17 was significantly associated with the history of self-harm and other proximal factors, but not with emotional dysregulation trajectory membership. Childhood trajectories featured by earlier emotional dysregulation were associated with higher risk of lifetime suicide attempt, as well as other proximal factors (concurrent self-harm). This study found differential risk profiles involved in both SRB forms. A relationship between early emotional dysregulation and suicide attempt engagement in adolescence was identified. Early interventions should be developed to deal with SRB risk factors from childhood.

Emotion regulation in bipolar disorder type-I: multivariate analysis of fMRI data

BACKGROUND

Bipolar disorder type-I (BD-I) patients are known to show emotion regulation abnormalities. In a previous fMRI study using an explicit emotion regulation paradigm, we compared responses from 19 BD-I patients and 17 matched healthy controls (HC). A standard general linear model-based univariate analysis revealed that BD patients showed increased activations in inferior frontal gyrus when instructed to decrease their emotional response as elicited by neutral images. We implemented multivariate pattern recognition analyses on the same data to examine if we could classify conditions within-group as well as HC versus BD.

METHODS

We reanalyzed explicit emotion regulation data using a multivariate pattern recognition approach, as implemented in PRONTO software. The original experimental paradigm consisted of a full 2 × 2 factorial design, with valence (Negative/Neutral) and instruction (Look/Decrease) as within subject factors.

RESULTS

The multivariate models were able to accurately classify different task conditions when HC and BD were analyzed separately (63.24%-75.00%, p = 0.001-0.012). In addition, the models were able to correctly classify HC versus BD with significant accuracy in conditions where subjects were instructed to downregulate their felt emotion (59.60%-60.84%, p = 0.014-0.018). The results for HC versus BD classification demonstrated contributions from the salience network, several occipital and frontal regions, inferior parietal lobes, as well as other cortical regions, to achieve above-chance classifications.

CONCLUSIONS

Our multivariate analysis successfully reproduced some of the main results obtained in the previous univariate analysis, confirming that these findings are not dependent on the analysis approach. In particular, both types of analyses suggest that there is a significant difference of neural patterns between conditions within each subject group. The multivariate approach also revealed that reappraisal conditions provide the most informative activity for differentiating HC versus BD, irrespective of emotional valence (negative or neutral). The current results illustrate the importance of investigating the cognitive control of emotion in BD. We also propose a set of candidate regions for further study of emotional control in BD.

Emotion regulation and cortisol response to the still-face procedure in preterm and full-term infants

In infancy, stress responses and emotion regulation are often coupled. Both are impacted by prematurity, though their relationship to one another in the case of infants born preterm is not fully understood. We investigated emotion regulation behaviours, cortisol reactivity and recovery and coupling between emotion regulation and cortisol reactivity to and recovery from a stressor in preterm infants. 53 preterm and 67 full-term infants with mean (range) gestational age at birth 29⁺³ (24⁺⁰-31⁺⁶) and 39⁺³ (36⁺²-42⁺⁰) weeks respectively were exposed to a socio-emotional stressor, the still-face (SF) paradigm, at 9 months of age (corrected for prematurity). The duration of negative affect and self-comforting behaviours exhibited in response to the SF, coded from a 10-minute video-taped interaction, were compared between groups. Saliva was collected from a subset (20 preterm, 24 term infants) at three timepoints: pre-SF and 20- and 30-minutes post SF. Cortisol concentrations at each timepoint were compared between groups. Associations between behavioural measures and cortisol concentrations were explored. There was no significant difference in duration of self-comforting behaviour between preterm and term infants. Preterm infants spent a significantly smaller proportion of time in a negative affective state compared to term infants (0.18 vs 0.25 s, p = 0.03). Salivary cortisol concentration was significantly higher in the preterm compared to the term group 30 min post SF (2.85 vs 1.77 nmol/L, p = 0.009), though findings were no longer significant after adjusting for time of day of sampling and socioeconomic deprivation. After controlling for time of day, greater negative affect was correlated with higher cortisol concentration 30 min post SF in the full-term (r = 0.58, p = 0.004) but not the preterm group (r = -0.01, p > 0.05). Our findings suggest altered response to an acute stressor in preterm infants, manifesting as a muted emotional response, and a lack of coupling between endocrine and behavioural stress response. Replication studies in larger samples would help to further understand biological stress repose in preterm infants and its relationship to behaviour, time of day and deprivation.

Emotion regulation in pediatric bipolar disorder: A meta-analysis of published studies

BACKGROUND

Emotion regulation is a relatively recent topic in psychiatry, and has only recently begun to be tested across Pediatric Bipolar Disorder (PBD). To date, no meta-analysis has investigated the presence of emotion regulation deficits in PBD patients.

OBJECTIVES

The aim of this study is to understand where the literature stands on this topic, as well as how different researchers are measuring and grasping the concept of emotion regulation in pediatric bipolar disorders.

METHODS

A systematic search of trials using the terms ("Pediatric Bipolar Disorder") AND ("Emotion Regulation" OR "Affect Regulation" OR "Mood Lability" OR "Mood Instability" OR "Irritability") was conducted using PubMed, Google Scholar, ResearchGate, Web of Science and Psych Info databases. Of the initial 366 articles identified, 8 met eligibility criteria for the meta-analysis and were included in this study.

RESULTS

There is a statistically significant difference in Accuracy in Emotion Regulation tasks, with a tendency for lower accuracy in PBD patients; however, both groups did not differ statistically regarding Response Time.

CONCLUSION

Our data suggests that PBD patients do present emotion regulation deficits, particularly regarding facial emotion recognition and affective language interference tasks mediated by cognitive assignments. These results have important implications in developing novel psychotherapeutic interventions for this population.

Interpretation bias training for bipolar disorder: A randomized controlled trial

BACKGROUND

Bipolar disorder (BD) is associated with emotion interpretation biases that can exacerbate depressed mood. Interpretation bias training (IBT) may help; according to the "virtuous cycle" hypothesis, interpreting others' emotions as positive can lead to interactions that improve mood. Our goals were to determine whether IBT can shift emotion interpretation biases and demonstrate clinical benefits (lower depressed mood, improved social function) in people with BD.

METHOD

Young adults with BD were recruited for three sessions of computer-based IBT. Active IBT targets negative emotion bias by training judgments of ambiguous face emotions towards happy judgments. Participants were randomized to active or sham IBT. Participants reported on mood and functioning at baseline, intervention end (week two), and week 10.

RESULTS

Fifty participants (average age 22, 72% female) enrolled, 38 completed the week 10 follow-up. IBT shifted emotion interpretations (Hedges g = 1.63). There was a group-by-time effect (B = -13.88, p < .0001) on self-reported depression; the IBT group had a larger decrease in depressed mood. The IBT group also had a larger increase in perceived familial support (B = 3.88, p < .0001). Baseline learning rate (i.e., how quickly emotion judgments were updated) was associated with reduced clinician- (B = -54.70, p < 0.001) and self-reported depression (B = -58.20, p = 0.009).

CONCLUSION

Our results converge with prior work demonstrating that IBT may reduce depressed mood. Additionally, our results provide support for role of operant conditioning in the treatment of depression. People with BD spend more time depressed than manic; IBT, an easily disseminated intervention, could augment traditional forms of treatment without significant expense or side effects.

Symptomatological Variants and Related Clinical Features in Adult Attention Deficit Hyperactive Disorder

A large amount of the current literature has focused on the characteristic symptoms of attention deficit hyperactivity disorder (ADHD) in children and adolescents. In contrast, less attention has been devoted to ADHD clinical subtypes in adult patients. We evaluated 164 consecutive adult ADHD (A-ADHD) outpatients using DSM-5 criteria and many specific rating scales and questionnaires. A principal component factor analysis was performed on clinical and symptomatological variables to describe potential clinical variants. We sought to determine different A-ADHD variants focusing on demographic and clinical features. A four-factor solution was identified, and patients were clustered, according to their z-score, in 4 subgroups. The first was marked out by Emotional Dysregulation (ED), the second by Substance Use (SU), the third by Core-ADHD Symptoms (Co-ADHD) and the fourth by Positive Emotionality (PE). Predominantly ED patients showed worse overall function, early treatment with antidepressants and a greater presence of borderline personality disorder than predominantly Co-ADHD patients. Predominantly SU patients reported high rates of bipolar disorder and severe general psychopathology. The PE factor was related to hyperthymic temperament and hypomania and showed a higher level of functioning. Females with A-ADHD showed a lower risk of being included in SU, and A-ADHD patients with co-occurring delayed sleep phase had less risk of being included in the SU factor than the prevailing Co-ADHD group. Our empirically based description of four clinical A-ADHD variants shows several aspects beyond the definition given by the DSM-5 diagnostic criteria.

A Preliminary Study on the Functional Benefits of Computerized Working Memory Training in Children With Pediatric Bipolar Disorder and Attention Deficit Hyperactivity Disorder

Twenty-nine pediatric patients (age range, 10–16 years) with working memory (WM) deficits, including children with pediatric bipolar disorder (PBD) with and without attention-deficit hyperactivity disorder (ADHD) comorbidity and children with ADHD, underwent a Cogmed WM training program. For both patient groups, WM performance on Cogmed tasks and on the Digit Span test improved significantly after training. Moreover, the PBD group improved on Trails Making Test A and on the Inhibition Scale, the Behavior Regulation Index, and the Global Executive Composite of the Behavioral Rating Inventory of Executive Function. The ADHD group improved significantly on the Trails Making Test B, the Spatial Span Test, and the Reading Fluency Test of the Woodcock–Johnson III, as well as on depressive symptoms. The present findings suggest that working memory training is beneficial not only in youths with ADHD but also in youths with PBD. They also show evidence of near and far transfer of WM improvement in these patients, although in different ways for the two patient groups. Future studies examining the mechanisms of cognitive remediation in pediatric patients will aid in creating tailored illness-specific cognitive interventions.

The role of emotion regulation in childhood obesity: implications for prevention and treatment

Stress and negative emotions pose a major threat to public health, by increasing the risk of obesity. Since the management process for emotions (emotion regulation; ER) is developed in childhood, we present a novel conceptual framework model for the role of ER in the prevention and treatment of childhood obesity. A narrative review of the literature by electronic database search (MEDLINE, Web of Knowledge and Scopus) was conducted of observational and interventional/experimental literature on ER and obesity and the underlying concepts. We also present an overview of ER intervention techniques. Our model indicates that childhood ER is a link between stress and obesity. Stress along with ineffective ER leads to abnormal cortisol patterns, emotional eating, sedentary lifestyle, reduction of physical activity, and sleep problems. Simultaneously, a healthy lifestyle could show benefits on ER and in developing adaptive ER strategies. In the development of obesity and ER, parents also play a role. By contrast, effective ER skills decrease obesity-related unhealthy behaviour and enhance protective factors, which boost health. The literature contains some observational studies of children but very few intervention studies, most of which are pilot or on-going studies. In conclusion, encouraging effective ER could be a useful new approach for combating and treating childhood obesity. Future ER intervention studies are needed to confirm the validity of this model in children.

Emotion regulation across childhood and adolescence: evidence for a maladaptive shift in adolescence

Dysfunctional emotion regulation is an important predictor of psychopathology. Although many clinical programs focus on emotion regulation skills, the successful application of these programs in children and adolescents requires knowledge on the normative use of emotion regulation strategies over age. To this end, the current cross-sectional study examined changes in emotion regulation throughout childhood and adolescence. The use of seven adaptive and five maladaptive emotion regulation strategies was measured with the FEEL-KJ in a representative sample (N = 1397) of Dutch children and adolescents between 8 and 18 years old. Overall, the results indicated reduced use of adaptive strategies and increased use of maladaptive strategies in participants between 12 and 15 years old compared with younger or older participants. The findings of the current study indicate that adolescence is characterized by a maladaptive shift in emotion regulation. Given that the continued use of dysfunctional emotion regulation plays an important role in the development and maintenance of psychopathology, these results highlight the importance of prevention and treatment programs focused on emotion regulation to shield vulnerable adolescents against mental illness.

The neurobiology of self-knowledge in depressed and self-injurious youth

There is limited information regarding the neurobiology underlying non-suicidal self-injury (NSSI) in clinically-referred youth. However, the salience of disturbed interpersonal relationships and disrupted self-processing associated with NSSI suggests the neural basis of social processes as a key area for additional study. Adolescent participants (N=123; M=14.75 years, SD=1.64) were divided into three groups: NSSI plus depression diagnosis (NSSI), depression only (DEP), healthy controls (HC). In the scanner, participants completed an Interpersonal Self-Processing task by taking direct (own) and indirect (mothers', best friends', or classmates') perspectives regarding self-characteristics. Across all perspectives, NSSI showed higher BOLD activation in limbic areas, and anterior and posterior cortical midline structures versus DEP and HC, while HC showed greater activity in rostrolateral, frontal pole and occipital cortex than NSSI and DEP youth. Moreover, NSSI youth showed heightened responses in amygdala, hippocampus, parahippocampus, and fusiform when taking their mothers' perspective, which were negatively correlated with self-reports of the mother's support of adolescents' emotional distress in the NSSI group. NSSI youth also yielded greater precuneus and posterior cingulate cortex activity during indirect self-processing from their classmates' perspective. Findings suggest a role for disruptions in self- and emotion-processing, and conflicted social relationships in the neurobiology of NSSI among depressed adolescents.

Disruptive Mood Dysregulation Disorder at Ages 13-18: Results from the National Comorbidity Survey-Adolescent Supplement

OBJECTIVE

"Disruptive mood dysregulation disorder" (DMDD) has been introduced into the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. but the utility of this new label and the clinical correlates of the children it describes are yet to be determined.

METHODS

A proxy for the DMDD diagnosis was extracted from the National Comorbidity Survey - Adolescent Supplement (NCS-A) data on 6483 adolescents (51.4% female) including Composite International Diagnostic Interview (CIDI) diagnoses and measures of impaired functioning from the Sheehan Disability Scale. Cross tabulations and logistic regression were used to assess for prevalence and comorbidity.

RESULTS

A total of 310 (5.26%) adolescents met the criteria for DMDD when diagnostic hierarchy and frequency of outbursts were not considered. At the low end of prevalence estimation, only nine adolescents (0.12%) met the most stringent proxy diagnosis, and they also met criteria for a number of comorbid disorders and functional impairment. The rates of comorbidity and functional impairment in adolescents with bipolar disorder were the same, irrespective of their meeting criteria for DMDD.

CONCLUSIONS

The DMDD diagnosis captures a small group of adolescents with multiple other psychiatric and neurologic conditions. The specificity of this diagnostic label, therefore, at least in adolescents, remains an open question.

Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial

OBJECTIVE

The purpose of this study was to conduct a pilot randomized trial of dialectical behavior therapy (DBT) versus psychosocial treatment as usual (TAU) for adolescents diagnosed with bipolar disorder (BP).

METHODS

We recruited participants 12-18 years of age with a primary BP diagnosis (I, II, or operationalized not otherwise specified [NOS] criteria) from a pediatric specialty clinic. Eligible patients were assigned using a 2:1 randomization structure to either DBT (n=14) or psychosocial TAU (n=6). All patients received medication management from a study-affiliated psychiatrist. DBT included 36 sessions (18 individual, 18 family skills training) over 1 year. TAU was an eclectic psychotherapy approach consisting of psychoeducational, supportive, and cognitive behavioral techniques. An independent evaluator, blind to treatment condition, assessed outcomes including affective symptoms, suicidal ideation and behavior, nonsuicidal self-injurious behavior, and emotional dysregulation, quarterly over 1 year.

RESULTS

Adolescents receiving DBT attended significantly more therapy sessions over 1 year than did adolescents receiving TAU, possibly reflecting greater engagement and retention; both treatments were rated as highly acceptable by adolescents and parents. As compared with adolescents receiving TAU, adolescents receiving DBT demonstrated significantly less severe depressive symptoms over follow-up, and were nearly three times more likely to demonstrate improvement in suicidal ideation. Models indicate a large effect size, for more weeks being euthymic, over follow-up among adolescents receiving DBT. Although there were no between-group differences in manic symptoms or emotional dysregulation with treatment, adolescents receiving DBT, but not those receiving TAU, evidenced improvement from pre- to posttreatment in both manic symptoms and emotional dysregulation.

CONCLUSIONS

DBT may offer promise as an adjunct to pharmacotherapy in the treatment of depressive symptoms and suicidal ideation for adolescents with BP. The DBT focus on commitment to treatment may be important for the treatment of early-onset BP. Larger controlled trials are needed to establish the efficacy of this approach, examine impact on suicidal behavior, and demonstrate cost effectiveness.

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.

Psychological factors that may confer risk for bipolar disorder

Several psychological domains may be dysfunctional in people with bipolar disorder (BD). When dysfunction occurs prior to onset of mood symptoms, it may signify risk for onset of the full syndrome of illness. Among these domains, cognitive dysfunction has received considerable attention as a possible endophenotype for BD, with some suggestion that changes in cognitive function may antedate onset of mood symptoms in individuals at risk for BD. Domains of social cognition, including emotion comprehension, theory of mind, and empathy, along with autobiographical memory, represent understudied aspects of psychological function that may be dysfunctional in people with BD. Temperament and personality factors, such as ruminative tendencies and neuroticism, may also leave some people vulnerable to mood instability. This review summarises the evidence for dysfunction in each of these domains for people with BD and examines whether there is any evidence that this dysfunction antedates the onset of mood symptoms or confers risk for illness.

An fMRI investigation of responses to peer rejection in adolescents with autism spectrum disorders

Peer rejection is particularly pervasive among adolescents with autism spectrum disorders (ASD). However, how adolescents with ASD differ from typically developing adolescents in their responses to peer rejection is poorly understood. The goal of the current investigation was to examine neural responses to peer exclusion among adolescents with ASD compared to typically developing adolescents. Nineteen adolescents with ASD and 17 typically developing controls underwent fMRI as they were ostensibly excluded by peers during an online game called Cyberball. Afterwards, participants reported their distress about the exclusion. Compared to typically developing adolescents, those with ASD displayed less activity in regions previously linked with the distressing aspect of peer exclusion, including the subgenual anterior cingulate and anterior insula, as well as less activity in regions previously linked with the regulation of distress responses during peer exclusion, including the ventrolateral prefrontal cortex and ventral striatum. Interestingly, however, both groups self-reported equivalent levels of distress. This suggests that adolescents with ASD may engage in differential processing of social experiences at the neural level, but be equally aware of, and concerned about, peer rejection. Overall, these findings contribute new insights about how this population may differentially experience negative social events in their daily lives.

Fronto-limbic function in unaffected offspring at familial risk for bipolar disorder during an emotional working memory paradigm

Evidence from neuroimaging studies indicate that individuals with bipolar disorder (BD) exhibit altered functioning of fronto-limbic systems implicated in voluntary emotion regulation. Few studies, however, have examined the extent to which unaffected youth at familial risk for BD exhibit such alterations. Using an fMRI emotional working memory paradigm, we investigated the functioning of fronto-limbic systems in fifteen healthy bipolar offspring (8-17 years old) with at least one parent diagnosed with BD (HBO), and 16 age-matched healthy control (HC) participants. Neural activity and functional connectivity analyses focused on a priori neural regions supporting emotion processing (amygdala and ventral striatum) and voluntary emotion regulation (ventrolateral prefrontal cortex (VLPFC), dorsolateral prefrontal cortex (DLPFC), and anterior cingulate cortex (ACC)). Relative to HC, HBO exhibited greater right VLPFC (BA47) activation in response to positive emotional distracters and reduced VLPFC modulation of the amygdala to both the positive and negative emotional distracters; there were no group differences in connectivity for the neutral distracters. These findings suggest that alterations in the functioning of fronto-limbic systems implicated in voluntary emotion regulation are present in unaffected bipolar offspring. Future longitudinal studies are needed to determine the extent to which such alterations represent neurodevelopmental markers of risk for future onset of BD.

I know it when I quantify it: ecological momentary assessment and recurrence quantification analysis of emotion dysregulation in children with ADHD

Two studies examined the feasibility, utility, and validity of Ecological Momentary Assessment (EMA) and Recurrence Quantification Analysis (RQA) in assessing emotion dysregulation in children with Attention-Deficit/Hyperactivity Disorder (ADHD). In Study 1, 11 parents of children with ADHD ages 8-11 completed EMA-based ratings of their children's mood three times daily for 28 days (84 ratings total) and questionnaires regarding their children's emotion dysregulation. RQA was used to quantify the temporal patterning of dysregulation of the children's mood. In Study 2, five children ages 8-11 completed EMA-based ratings of their mood three times daily for 28 days. Results supported the feasibility and validity of the parent report EMA protocol, with greater intensity, variability, and persistent patterning of variability associated with greater emotion dysregulation. Results did not support the validity of the child report protocol, as children were less likely to complete ratings when emotionally distressed and demonstrated substantial response bias.

Deficits in emotion recognition in pediatric bipolar disorder: the mediating effects of irritability

BACKGROUND

Pediatric Bipolar Disorder (PBD) is a debilitating condition associated with impairment in many domains. Social functioning is one of the disorder's most notable areas of impairment and this deficit may be in part due to difficulties recognizing affect in others.

METHODS

In the present study, medication naïve youth with PBD were compared to age-matched healthy controls on their ability to (a) distinguish between categorical emotions, such as happiness, anger, and sadness on the Emotion Recognition Test (ER-40) and (b) differentiate between levels of emotional intensity on an adapted version of the Penn Emotional Acuity Task (Chicago-PEAT).

RESULTS

Results indicated that PBD youth misidentified sad, fearful, and neutral faces more often than controls, and PBD girls mislabeled 'very angry' faces more often than healthy girls. A mediation analyses indicated that these diagnostic group differences on emotion recognition were significantly mediated by irritability.

LIMITATIONS

The Chicago-PEAT only examined variations in emotional intensity for the emotions happy and anger. Additionally, all results are correlational; therefore causal inferences cannot be made.

CONCLUSIONS

Supporting previous literature, the present findings highlight the importance of emotion recognition deficits in PBD individuals. Additionally, the irritability associated with PBD may be an important mechanism of this deficit and may thus represent an important target for treatment.

Systematic review of the neural basis of social cognition in patients with mood disorders

BACKGROUND

This review integrates neuroimaging studies of 2 domains of social cognition--emotion comprehension and theory of mind (ToM)--in patients with major depressive disorder and bipolar disorder. The influence of key clinical and method variables on patterns of neural activation during social cognitive processing is also examined.

METHODS

Studies were identified using PsycINFO and PubMed (January 1967 to May 2011). The search terms were "fMRI," "emotion comprehension," "emotion perception," "affect comprehension," "affect perception," "facial expression," "prosody," "theory of mind," "mentalizing" and "empathy" in combination with "major depressive disorder," "bipolar disorder," "major depression," "unipolar depression," "clinical depression" and "mania."

RESULTS

Taken together, neuroimaging studies of social cognition in patients with mood disorders reveal enhanced activation in limbic and emotion-related structures and attenuated activity within frontal regions associated with emotion regulation and higher cognitive functions. These results reveal an overall lack of inhibition by higher-order cognitive structures on limbic and emotion-related structures during social cognitive processing in patients with mood disorders. Critically, key variables, including illness burden, symptom severity, comorbidity, medication status and cognitive load may moderate this pattern of neural activation.

LIMITATIONS

Studies that did not include control tasks or a comparator group were included in this review.

CONCLUSION

Further work is needed to examine the contribution of key moderator variables and to further elucidate the neural networks underlying altered social cognition in patients with mood disorders. The neural networks under lying higher-order social cognitive processes, including empathy, remain unexplored in patients with mood disorders.

Differential patterns of abnormal activity and connectivity in the amygdala-prefrontal circuitry in bipolar-I and bipolar-NOS youth

OBJECTIVE

The functioning of neural systems supporting emotion processing and regulation in youth with bipolar disorder not otherwise specified (BP-NOS) remains poorly understood. We sought to examine patterns of activity and connectivity in youth with BP-NOS relative to youth with bipolar disorder type I (BP-I) and healthy controls (HC).

METHOD

Participants (18 BP-I youth, 16 BP-NOS youth, and 18 HC) underwent functional magnetic resonance imaging while performing two emotional-face gender labeling tasks (happy/neutral, fearful/neutral). Analyses focused on a priori neural regions supporting emotion processing (amygdala) and emotion regulation (ventromedial prefrontal cortex (VMPFC), dorsolateral prefrontal cortex (DLPFC). Connectivity analyses used VMPFC as a seed region.

RESULTS

During the happy-face task, BP-I youth had greater amygdala, VMPFC, and DLPFC activity to happy faces whereas BP-NOS youth had reduced VMPFC and DLPFC activity to neutral faces relative to HC, and reduced amygdala, VMPFC, and DLPFC activity to neutral faces versus BP-I. During the fearful-face task, BP-I youth had reduced DLPFC activity to fearful faces whereas BP-NOS youth had reduced DLPFC activity to neutral faces relative to HC. BP-NOS youth showed greater VMPFC-DLPFC connectivity to happy faces relative to HC and BP-I youth. BP-I youth showed reduced VMPFC-amygdala connectivity to fearful faces relative to HC and BP-NOS youth.

CONCLUSIONS

This is the first study to document differential patterns of abnormal neural activity in, and connectivity between, neural regions supporting emotion processing and regulation in BP-NOS versus BP-I youth. Findings suggest that despite similarities in symptom presentation, there are differential patterns of abnormal neural functioning in BP-NOS and BP-I relative to HC, which might reflect an "intermediate state" in the course of BP-I illness. Future longitudinal studies are needed to relate these findings with future conversion to BP-I/II.

Progression of amygdala volumetric abnormalities in adolescents after their first manic episode

OBJECTIVE

Although previous neuroimaging studies suggest that adolescents with bipolar disorder exhibit smaller amygdala volumes compared with healthy adolescents, whether these abnormalities are present at illness onset or instead develop over time remains unclear. The aim of this study was to conduct a prospective longitudinal investigation comparing amygdala neurodevelopment among adolescents after their first manic episode, adolescents with attention-deficit/hyperactivity disorder (ADHD), and healthy adolescents.

METHOD

A total of 30 adolescents hospitalized for their first manic/mixed episode associated with bipolar disorder, 29 adolescents with ADHD, and 24 demographically matched healthy teens underwent magnetic resonance imaging scanning at index assessment and approximately 12 months later. Adolescents with bipolar disorder were prospectively evaluated using diagnostic interviews and with symptom rating scales.

RESULTS

Mixed models examining the group × time effect for both left (p = .005) and right (p = .002) amygdala volumes were statistically significant. Change in left (p = .01) and right (p = .0008) amygdala volumes from baseline to 12 months were significantly different among groups. Specifically, left amygdala volumes increased over time in healthy adolescents (p = .008) and adolescents with ADHD (p = .0009), but not in adolescents with bipolar disorder (p = .3). Right amygdala volume increased over time in adolescents with ADHD (p < .001), but not in healthy adolescents nor in adolescents with bipolar disorder (p = .1 and p = .3, respectively). In adolescents with bipolar disorder, baseline total amygdala volume was significantly greater in those who subsequently achieved symptomatic recovery as compared with those who did not achieve recovery (p = .02).

CONCLUSIONS

Adolescents with mania do not exhibit normal increases in amygdala volume that occur during healthy adolescent neurodevelopment.

Face processing in attention deficit/hyperactivity disorder

ADHD is one of the most common and impairing psychiatric conditions affecting children today. Thus far, much of the phenomenological and neurobiological research has emphasized the core symptoms of inattention, hyperactivity, and impulsivity which are thought to be mediated by frontostriatal alterations. However, increasing evidence suggests that ADHD involves emotional problems in addition to cognitive impairments. Here, we review the neurobiology of face processing and suggest that face-processing alterations offer a window into the emotional dysfunction often accompanying ADHD.

Research Review: 'Ain't misbehavin': Towards a developmentally-specified nosology for preschool disruptive behavior

There is increasing consensus that disruptive behavior disorders and syndromes (DBDs) are identifiable in preschool children. There is also concomitant recognition of the limitations of the current DBD nosology for distinguishing disruptive behavior symptoms from the normative misbehavior of early childhood. In particular, there appears to be substantial insensitivity to heterotypic manifestations of this developmental period and problems in identifying meaningful heterogeneity. As a result, the developmental basis for much of the current nosology may be called into question. To address these and other critical issues, this paper reviews the foundational elements of clinical and developmental science pertinent to developmental differentiation of disruptive behavior in the preschool period as paradigmatic for developmental specification across the lifespan and generates an agenda for future research. We begin by reviewing evidence of the validity of DBDs in preschool children. This is followed by an outline of key developmental concepts and a review of the corollary evidence from developmental science. These provide a basis for conceptualizing disruptive behavior in reference to developmental deviation in four core dimensions hypothesized to mark the core features of disruptive behavior syndromes. Finally, we propose a program of research to establish an empirical basis for determining the incremental utility of a developmentally specified nosology. Central to this approach is a contention that the benefits of developmental specification are extensive and outweigh any disadvantages. This is because a developmentally specified approach holds substantial promise for increasing sensitivity and specificity for differentiating disruptive behavior from normative misbehavior and from other related syndromes as well as for improving prediction. Further, more precisely defined, developmentally based phenotypes are likely to elucidate distinct mechanisms within translational studies and to serve as a catalyst for the generation of novel treatments.

Child Behavior Checklist Juvenile Bipolar Disorder (CBCL-JBD) and CBCL Posttraumatic Stress Problems (CBCL-PTSP) scales are measures of a single dysregulatory syndrome

BACKGROUND

The Child Behavior Checklist Juvenile Bipolar Disorder (CBCL-JBD) profile and Posttraumatic Stress Problems (CBCL-PTSP) scale have been used to assess juvenile bipolar disorder (JBD) and posttraumatic stress disorder (PTSD), respectively. However, their validity is questionable according to previous research. Both measures are associated with severe psychopathology often encompassing multiple DSM-IV diagnoses. Further, children who score highly on one of these scales often have elevated scores on the other, independent of PTSD or JBD diagnoses. We hypothesized that the two scales may be indicators of a single syndrome related to dysregulated mood, attention, and behavior. We aimed to describe and identify the overlap between the CBCL-JBD profile and CBCL-PTSP scales.

METHOD

Two thousand and twenty-nine (2029) children from a nationally representative sample (1073 boys, 956 girls; mean age = 11.98; age range = 6-18) were rated on emotional and behavior problems by their parents using the CBCL. Comparative model testing via structural equation modeling was conducted to determine whether the CBCL-JBD profile and CBCL-PTSP scale are best described as measuring separate versus unitary constructs. Associations with suicidality and competency scores were also examined.

RESULTS

The CBCL-JBD and CBCL-PTSP demonstrated a high degree of overlap (r = .89) at the latent variable level. The best fitting, most parsimonious model was one in which the CBCL-JBD and CBCL-PTSP items identified a single latent construct, which was associated with higher parental endorsement of child suicidal behavior, and lower functioning.

CONCLUSIONS

The CBCL-JBD profile and CBCL-PTSP scale overlap to a remarkable degree, and may be best described as measures of a single syndrome. This syndrome appears to be related to severe psychopathology, but may not conform to traditional DSM-IV classification. These results contribute to the ongoing debate about the utility of the CBCL-JBD and CBCL-PTSP profiles, and offer promising methods of empirically based measurement of disordered self-regulation in youth.

Neural correlates of social exclusion during adolescence: understanding the distress of peer rejection

Developmental research has demonstrated the harmful effects of peer rejection during adolescence; however, the neural mechanisms responsible for this salience remain unexplored. In this study, 23 adolescents were excluded during a ball-tossing game in which they believed they were playing with two other adolescents during an fMRI scan; in reality, participants played with a preset computer program. Afterwards, participants reported their exclusion-related distress and rejection sensitivity, and parents reported participants' interpersonal competence. Similar to findings in adults, during social exclusion adolescents displayed insular activity that was positively related to self-reported distress, and right ventrolateral prefrontal activity that was negatively related to self-reported distress. Findings unique to adolescents indicated that activity in the subgenual anterior cingulate cortex (subACC) related to greater distress, and that activity in the ventral striatum related to less distress and appeared to play a role in regulating activity in the subACC and other regions involved in emotional distress. Finally, adolescents with higher rejection sensitivity and interpersonal competence scores displayed greater neural evidence of emotional distress, and adolescents with higher interpersonal competence scores also displayed greater neural evidence of regulation, perhaps suggesting that adolescents who are vigilant regarding peer acceptance may be most sensitive to rejection experiences.

Neural correlates of emotion processing in borderline personality disorder

Emotional instability is a hallmark feature of borderline personality disorder (BPD), yet its biological underpinnings are poorly understood. We employed functional magnetic resonance imaging (fMRI) to compare patterns of regional brain activation in BPD patients and healthy volunteers as they process positive and negative social emotional stimuli. fMRI images were acquired while 19 BPD patients and 17 healthy controls (HC) viewed emotion-inducing pictures from the International Affective Pictures System set. Activation data were analyzed with SPM5 ANCOVA models to derive the effects of diagnosis and stimulus type. BPD patients demonstrated greater differences in activation than controls, when viewing negative pictures compared with rest, in the amygdala, fusiform gyrus, primary visual areas, superior temporal gyrus (STG), and premotor areas, while healthy controls showed greater differences than BPD patients in the insula, middle temporal gyrus and dorsolateral prefrontal cortex (BA46). When viewing positive pictures compared with rest, BPD patients showed greater differences in the STG, premotor cortex, and ventrolateral prefrontal cortex. These findings suggest that BPD patients show greater amygdala activity and heightened activity of visual processing regions relative to findings for HC subjects in the processing of negative social emotional pictures compared with rest. The patients activate neural networks in emotion processing that are phylogeneticall older and more reflexive than those activated by HC subjects.

Affect regulation in pediatric bipolar disorder

Increasingly, clinicians and researchers alike are describing children presenting with emotional and behavioral problems as suffering from deficits of "affect regulation." The present article reviews the current understanding of affect regulation. The authors also discuss recent findings implicating affect dysregulation in children and adolescents with bipolar disorder.

A quantitative and qualitative review of neurocognitive performance in pediatric bipolar disorder

Bipolar disorder (BD) is an increasingly prevalent diagnosis in youth. As a result, there has been a corresponding increase in interest about neuropsychological and cognitive profiles in children and adolescents diagnosed with BD. Meta-analysis of the existing literature comparing individuals with BD to healthy controls indicated that the largest differences are observed for measures of verbal memory (d = 0.77). Moderate differences were found in the areas of attention (d = 0.62), executive functioning (d = 0.62), working memory (d = 0.60), visual memory (d = 0.51), visual perceptual skills (d = 0.48), and verbal fluency (d = 0.45). Small differences were found for measures of reading (d = 0.40), motor speed (d = 0.33), and full-scale intelligence quotient (IQ) (d = 0.32). Often, few studies have provided relevant information for a particular neurocognitive domain. Despite this, several domains displayed heterogeneity of effect sizes across studies. Methodological factors explained the variance in effect sizes to different extents depending upon the cognitive domain. The changing influence of method artifacts is likely due to variable coverage of cognitive domains across studies and the use of different measures across studies. Findings are consistent with previous meta-analyses of the adult BD neurocognitive literature, suggesting that many of the deficits observed in adults are present earlier in the course of the illness. Study reporting guidelines are offered that may help clarify the impact of illness definitions, mood state, medication status, and other methodological variables on neurocognition in pediatric BD.

A neural model of voluntary and automatic emotion regulation: implications for understanding the pathophysiology and neurodevelopment of bipolar disorder

The ability to regulate emotions is an important part of adaptive functioning in society. Advances in cognitive and affective neuroscience and biological psychiatry have facilitated examination of neural systems that may be important for emotion regulation. In this critical review we first develop a neural model of emotion regulation that includes neural systems implicated in different voluntary and automatic emotion regulatory subprocesses. We then use this model as a theoretical framework to examine functional neural abnormalities in these neural systems that may predispose to the development of a major psychiatric disorder characterized by severe emotion dysregulation, bipolar disorder.

Comparison of diagnostic guidelines for juvenile bipolar disorder

The purpose of the present paper was to compare currently available diagnostic guidelines for juvenile bipolar disorder with respect to utility in research and clinical practice. A systematic search of psychiatric, medical and psychological databases was conducted using the terms 'juvenile bipolar disorder', 'paediatric bipolar disorder' and 'guidelines'. Three main sets of guidelines issued by the National Institute of Health and Clinical Excellence (UK), The National Institute of Mental Health (USA) and Child Psychiatric Workshop (USA) were found. There were key differences in the recommendations made by each regarding the diagnosis and symptomatic presentation of juvenile bipolar disorder. Although the diagnosis of juvenile bipolar disorder is gaining increased recognition, its definition remains controversial. It is recommended that clinicians and researchers need to develop diagnostic guidelines that have clinical salience and can be used for future research by incorporating key features of those that are currently available.