The Child Behavior Checklist (CBCL) and the CBCL-bipolar phenotype are not useful in diagnosing pediatric bipolar disorder

Anxiety and Disruptive Behavior Symptoms and Disorders in Preschool-Age Offspring of Parents With and Without Bipolar Disorder: Associations With Parental Comorbidity

OBJECTIVE

We examined the relative contribution of parental bipolar disorder (BPD) and psychiatric comorbidities (disruptive behavior disorders [DBD] and anxiety disorders) in predicting psychiatric symptoms and disorders in 2-5-year-old offspring.

METHODS

Participants were 60 families with a parent with BPD and 78 offspring and 70 comparison families in which neither parent had a mood disorder and 91 offspring. Parent and offspring diagnoses and symptoms were assessed using standardized diagnostic interviews and measures, with offspring assessors masked to parental diagnoses.

RESULTS

Offspring of parents with BPD had significant elevations in behavioral, mood and anxiety disorders and symptoms. Both parental BPD and DBD contributed to elevations in child disruptive behavioral symptoms, whereas child anxiety symptoms were more strongly predicted by comorbid parental anxiety. Parental BPD was a stronger predictor than comorbid DBD of child DBDs.

CONCLUSION

Some of the elevated risk for disorders in preschoolers is accounted for by parental comorbidity.

Comparing two measures of neighborhood quality and internalizing and externalizing behaviors in the adolescent brain cognitive development study

PURPOSE

There is widespread recognition of the importance and complexity of measuring neighborhood contexts within research on child psychopathology. In this study, we assessed the cross-sectional associations between two measures of neighborhood quality and internalizing and externalizing behaviors in preadolescence.

METHODS

Drawing on baseline data from the Adolescent Brain Cognitive Development Study (n = 10,577 preadolescents), we examined two multi-component assessments of neighborhood quality in relation to children's internalizing and externalizing symptoms: the Area Deprivation Index (ADI), which measures socioeconomic adversity, and the Child Opportunity Index 2.0 (COI), which measures economic, educational, and environmental opportunity. Both measures were categorized into quintiles. We then used mixed-effects linear regression models to examine bivariate and adjusted associations.

RESULTS

The bivariate associations displayed strong inverse associations between the COI and ADI and externalizing symptoms, with a graded pattern of fewer externalizing behaviors with increasing neighborhood quality. Only the ADI was associated with externalizing behaviors in models adjusted for child and family characteristics. We did not observe a clear association between either measure of neighborhood quality and internalizing behaviors in bivariate or adjusted models.

CONCLUSIONS

Neighborhood quality, as measured by the COI and ADI, was associated with externalizing behaviors in preadolescent children. The association using the ADI persisted after adjustment for family-level characteristics, including financial strain. Our results indicate that different assessments of neighborhood quality display distinct associations with preadolescent behavioral health. Future research is needed to assess the association between neighborhood quality and behavior trajectories and to identify place-based intervention strategies.

Pediatric Bipolar Disorder: A Practical Guide for Clinicians

Pediatric bipolar disorder (PBD) is a controversial clinical entity and it still needs to be satisfactorily defined. Having a polymorphous presentation and associated with numerous symptoms of comorbid psychiatric illnesses often diagnosed during childhood and adolescence, including attention deficit hyperactivity disorder, its symptoms do not completely parallel those of bipolar disorder in adults. The clinician must be able to reach a diagnosis of PBD in the presence of fluctuating and atypical symptoms, especially in children, who tend to experience mixed episodes and very rapid cycles. Historically a key symptom for diagnosing PBD is episodic irritability. Proper diagnosis is critical due to the gravity of its prognosis. Clinicians may find supporting evidence for a diagnosis through careful study of the medical and developmental history of the young patient in addition to psychometric data. Treatment prioritizes psychotherapeutic intervention and assigns important roles to family involvement and a healthy lifestyle.

Further Evidence of an Association Between a Positive Child Behavior Checklist-Bipolar Profile and a Diagnosis of Pediatric Bipolar Disorder: A Meta-Analysis

Background

Previous research has found that a unique profile of the Child Behavior Checklist comprising of aggregate elevations of the Attention, Anxiety/Depression and Aggression scales (A-A-A profile, CBCL-Bipolar (BP) profile, CBCL-Dysregulation profile (DP); henceforth CBCL-BP/DP profile) is associated with a clinical diagnosis of pediatric bipolar (BP) disorder.

Objective

The main aim of the study is to evaluate the strength of the association between the CBCL-BP/DP profile and the clinical diagnosis of pediatric BP disorder through a meta-analysis.

Methods

A literature search was performed to identify studies that examined the association between a positive CBCL-BP/DP profile and a clinical diagnosis of pediatric BP disorder. The meta-analyses first examined studies assessing the rates of a positive CBCL-BP/DP profile in youth with BP disorder versus those with 1) ADHD, anxiety/depression, or disruptive behavior disorders (DBDs), and 2) non-bipolar controls. The second analysis evaluated studies examining the rates of pediatric BP disorder in youth with and without a positive CBCL-BP/DP profile.

Results

Eighteen articles met our inclusion and exclusion criteria, and fifteen articles had adequate data for meta-analysis. Results showed that BP youth were at significantly increased odds of having a positive CBCL-BP/DP profile compared to those with other psychiatric disorders (i.e., ADHD, anxiety/depression, or DBDs) (pooled OR=4.34, 95% CI=2.82, 8.27; p<0.001) and healthy control groups (pooled OR=34.77, 95% CI=2.87, 420.95; p=0.005). Further, meta-analysis results showed that youth with a positive CBCL-BP/DP profile were at significantly increased odds of having a BP disorder diagnosis compared to those without (pooled OR=4.25, 95% CI=2.12, 8.52; p<0.001).

Conclusion

Our systematic review and meta-analysis of the extant literature provides strong support for the association between the CBCL-BP/DP profile and pediatric BP disorder.

The role of genetic and environmental factors in covariation between anxiety and anger in childhood

Higher levels of anger expression, as well as lower levels of anger control, have been reported for adults with anxiety disorders compared to individuals without anxiety disorders. Different to the research on adults, very few studies examined the relationship between anxiety and anger in childhood. In our study, we investigated 398 Italian twin pairs (74 MZ male, 70 MZ female, 134 same-sex dizygotic-53 male, 81 female-, and 120 unlike-sex dizygotic twin pairs), aged 8-17 (mean 13.06 ± 2.59): (i) the heritability of a childhood anger phenotype; (ii) the association between five anxiety domains and anger; (iii) the role of possible common etiological factors in explaining the observed comorbidity and overlap in the risk between anxiety phenotypes and anger. The study demonstrated that anger, assessed by CBCL items, is heritable in children at a similar rate to prior studies (40%). Our research found low to moderate rate of correlation between anger and anxiety (from 0.10 to 0.19). Finally, the present study found that the majority of etiological influences on anxiety and anger are independent of each other. Data showed that shared environmental influences have some small effects on the phenotypic covariation between the anxiety phenotypes and anger (12%); whereas unique environmental influences have an almost negligible effect (1%). Our analyses did not reveal the effect of genetic effects in explaining the covariation between these phenotypes.

Early childhood internalizing problems, externalizing problems and their co-occurrence and (mal)adaptive functioning in emerging adulthood: a 16-year follow-up study

PURPOSE

A vast amount of studies suggest that internalizing or externalizing problems are related to individual functioning, and often co-occur. Yet, a focus on their additive and interactive effects is scarce. Furthermore, most research has focused on a limited number of developmental domains and mostly on maladaptive functioning. Therefore, the current prospective study examined whether early childhood (ages 4-8) internalizing and externalizing problems and their interaction were related to a broad range of (mal)adaptive functioning outcomes in emerging adulthood (ages 20-24).

METHODS

Data from the Flemish Study on Parenting, Personality and Development were used. At Time 1 (1999) mothers of 374 children (45% boys) and fathers of 357 children (46% boys) rated internalizing and externalizing problems through the Child Behavior Checklist. Outcomes in emerging adulthood were measured through self-reports 16 years later across the following domains: psychological functioning, social functioning, work, physical health, and self-concept.

RESULTS

Early externalizing problems were related to maladaptive outcomes on the psychological and social domains. With regard to adaptive functioning, externalizing problems were associated with lower satisfaction regarding general health on the physical domain. Early internalizing problems were not associated with any emerging adulthood outcomes. The interaction of (father reported) internalizing and externalizing problems was related to aggressive behavior.

CONCLUSION

Early childhood externalizing problems were associated with maladaptive and adaptive functioning over a time span of 16 years. The results add to studies on the implementation of prevention and intervention programs in early childhood and to the value for developing personalized interventions.

Receiver Operating Characteristic Curve Analysis of Screening Tools for Bipolar Disorder Comorbid With ADHD in Schoolchildren

Objective: We compared Child Behavior Checklist (CBCL)-AAA (Attention Problems, Aggressive Behavior, and Anxious/Depressed) and Parent-Young Mania Rating Scale (P-YMRS) profiles in Brazilian children with ADHD, pediatric-onset bipolar disorder (PBD), and PBD + ADHD. Method: Following analyses of variance or Kruskal-Wallis tests with multiple-comparison Least Significant Difference (LSD) or Dunn's Tests, thresholds were determined by Mann-Whitney U Tests and receiver operating characteristic (ROC) plots. Results: Relative to ADHD, PBD and PBD + ADHD groups scored higher on the Anxious/Depressed, Thought Problems, Rule-Breaking, and Aggressive Behavior subscales and Conduct/Delinquency Diagnostic Scale of the CBCL; all three had similar attention problems. The PBD and PBD + ADHD groups scored higher than the ADHD and healthy control (HC) groups on all CBCL problem scales. The AAA-profile ROC had good diagnostic prediction of PBD + ADHD. PBD and PBD-ADHD were associated with (similarly) elevated P-YMRS scores. Conclusion: The CBCL-PBD and P-YMRS can be used to screen for manic behavior and assist in differential diagnosis.

General Psychopathology and Dysregulation Profile in a Longitudinal Community Sample: Stability, Antecedents and Outcomes

The general factor of psychopathology (GP, or p factor) and the Dysregulation Profile (DP) are two conceptually similar, but independently developed approaches to understand psychopathology. GP and DP models and their stability, antecedents and outcomes are studied in a longitudinal sample of 1073 children (49.8% female). GP and DP models were estimated at ages 8 and 14 years using the parent-reported Child Behavior Checklist (CBCL) and Youth Self Report (YSR). Early childhood antecedents and adolescent outcomes were derived using a multi-method multi-informant approach. Results showed that the general GP and DP had similar key symptoms and were similarly related to early-childhood antecedents (e.g., lower effortful control, higher maternal depression) and adolescent outcomes (e.g., reduced academic functioning, poorer mental health). This study demonstrates that GP and DP are highly similar constructs in middle childhood and adolescence, both describing a general vulnerability for psychopathology with (emotional) dysregulation at its core. Scientific integration of these approaches could lead to a better understanding of the structure, antecedents and outcomes of psychopathology.

Diminished Protective Effects of Household Income on Internalizing Symptoms among African American than European American Pre-Adolescents

AIM

To investigate the differential role of race on the effect of household income on pre-adolescents' internalizing symptoms in a national sample of U.S. pre-adolescents.

METHODS

This is a cross-sectional study that used data from the Adolescent Brain Cognitive Development (ABCD) study. Wave 1 ABCD data included 5,913 adolescents between ages 9 and 10 years old. The independent variable was household income. The primary outcome was internalizing symptoms measured by the teacher report of the Brief Problem Monitor (BPM) scale.

RESULTS

Overall, high household income was associated with lower levels of pre-adolescents internalizing symptoms. Race showed statistically significant interaction with household income on pre-adolescents' internalizing symptoms, controlling for all confounders, indicating weaker protective effect of high household income on internalizing symptoms for African American than European pre-adolescents.

CONCLUSION

High household income is a more salient protective factor against internalizing symptoms of socially privileged European American pre-adolescents than of historically marginalized African Americans pre-adolescents. Elimination of internalizing behavioral gaps across racial groups requires more than equalizing socioeconomic status. Future research should study the moderating role of institutional and structural racism experienced by African American families across all income levels. Such research may explain why pre-adolescent African Americans with high household income remain at high risk of internalizing symptoms.

Sympathetic arousal in children with oppositional defiant disorder and its relation to emotional dysregulation

BACKGROUND

Emotional dysregulation (ED) is a trans-nosographical condition characterized by mood instability, severe irritability, aggression, temper outburst, and hyper-arousal. Pathophysiology of emotional dysregulation and its potential biomarkers are an emerging field of interest. A Child Behaviour Checklist (CBCL) profile, defined as Dysregulation Profile (DP), has been correlated to ED in youth. We examined the association between the CBCL-DP and indices of sympathetic arousal in children with Oppositional Defiant Disorder (ODD) and healthy controls.

METHOD

The current study sought to compare the arousal level measured via electrodermal activity in response to emotional stimuli in three non-overlapping groups of children: (1) ODD+CBCL-DP (n = 28), (2) ODD without CBCL-DP (n = 35), and (3) typically developing controls (n = 25).

RESULTS

Analyses revealed a distinct electrodermal activity profile in the three groups. Specifically, children with ODD+CBCL-DP presented higher levels of sympathetic arousal for anger and sadness stimuli compared to the other two groups.

LIMITATIONS

The relatively small sample and the lack of assessing causality limit the generalizability of this study which results need to be replicated in larger, different samples.

CONCLUSION

The CBCL-DP was associated to higher levels of arousal for negative emotions, consistently with previous reports in individuals with depression and anxiety. Further work may identify potential longitudinal relationships between this profile and clinical outcomes.

Neonatal Negative Emotionality and the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) in middle childhood

Objective: Determine whether an association exists between neonatal negative emotionality and childhood emotional dysregulation. Background: The Child Behaviour Checklist-Dysregulation Profile (CBCL-DP) has been used as a measure of emotional dysregulation in childhood. Although there is now good evidence that the CBCL-DP predicts later psychopathology, little is known about what factors predict elevations on the CBCL-DP. Methods: 30 mother-child dyads who previously participated in a study of neonatal temperament were recruited to a follow-up study of emotional dysregulation during middle childhood. The Neonatal Behaviour Assessment Scale (NBAS) and the Infant Characteristics Questionnaire (ICQ) were utilised as observer and maternal measures of neonatal negative emotionality, respectively. Maternal post-partum depression was also measured during the neonatal period using the Edinburgh Post-Partum Depression Scale (EPDS). The Child Behaviour Checklist-Dysregulation Profile (CBCL-DP) was used as a measure of childhood emotional dysregulation. Results: The ICQ fussy-difficult scale was significantly correlated with the CBCL-DP score (r = .46, p = .010), and this correlation remained significant after controlling for maternal EPDS score (CBCL-DP r = .51, p = .01). The NBAS irritability score was not associated with the CBCL-DP score. Conclusions: This association provides preliminary results that neonates rated as having high negative emotionality may indeed experience chronic difficulties with emotional dysregulation.

Clinical utility of the CBCL Dysregulation Profile in children with disruptive behavior

BACKGROUND

Children who are severely dysregulated experience a range of concurrent and long-term impairments and psychopathology and are particularly at-risk for mood and anxiety disorders. The Child Behavior Checklist Dysregulation Profile (CBCL-DP) may be useful in identifying children who are highly dysregulated, which could facilitate early intervention.

METHODS

We examined the prevalence, gender differences, parent-teacher agreement, and concurrent validity of two categorical definitions of the CBCL-DP in 348 children ages 6-12 who were clinic-referred for assessment and treatment because of disruptive behavior.

RESULTS

Rates of the CBCL-DP were 3 times higher when a less stringent versus a more stringent definition of the CBCL-DP was used (46.8% vs. 15.2%). Girls were more likely than boys to meet criteria for the CBCL-DP when the more stringent definition was used. Parent-teacher agreement was low, particularly when the more stringent definition of the CBCL-DP was used. Children with the CBCL-DP were rated by their parents, but not their teachers, as more impaired than other children, regardless of the definition of the CBCL-DP used, and even when compared to children with clinically elevated scores on other CBCL subscales.

LIMITATIONS

Our cross-sectional data did not allow us to examine the predictive validity of the CBCL-DP, informant effects may have inflated associations between CBCL-DP and parent-rated impairment, and teacher ratings were missing for many children.

CONCLUSIONS

Our findings support other reports that provide evidence that the CBCL-DP may identify a particularly symptomatic and impaired group of children with disruptive behavior, as rated by their parents.

Further Evidence of the Diagnostic Utility of the Child Behavior Checklist for Identifying Pediatric Bipolar I Disorder

Background:

Pediatric bipolar (BP) disorder is a prevalent and highly morbid disorder. While structured diagnostic interviews have been developed to aid in the diagnosis of pediatric BP disorder, these tools are lengthy, costly and not widely available. One possible diagnostic aid is the Child Behavior Checklist (CBCL).

Objective:

To assess the diagnostic utility of the CBCL-BP profile to identify children with a diagnosis of BP-I disorder.

Method:

Subjects were derived from four independent data sets of children and adolescents with and without attention deficit hyperactivity disorder and BP-I. Subjects were recruited from pediatric and psychiatric clinics and the community. All subjects had structured clinical interviews with raters blinded to subject ascertainment status. We used an empirically derived profile from the CBCL consisting of an aggregate t-score from the Attention, Anxiety/Depression and Aggression subscales (CBCL-BP profile) to operationalize the presence or absence of BP symptoms. Receiver operating characteristic (ROC) curves were used to examine the ability of the CBCL-BP profile to identify children with and without a structured interview diagnosis of BP-I disorder.

Results:

The sample consisted of 661 subjects (mean age: 11.7 ± 3.3 years, 57% male and 94% Caucasian). In total, 20 percent of participants (n = 130) met structured interview criteria for a full diagnosis of BP-I disorder. The ROC analysis of the CBCL-BP profile yielded an area under the curve (AUC) of 0.91. A t-score of ≥ 195 on the CBCL-BP profile correctly classified 86% of subjects with BP-I disorder with 80% sensitivity, 87% specificity, 61% positive predictive value (PPV) and 95% negative predictive value (NPV).

Conclusion:

The CBCL-BP profile efficiently discriminated pediatric subjects with and without a structured interview diagnosis of BP-I disorder. Findings suggest that the CBCL-BP profile may be an efficient tool to help identify children who are very likely to suffer from BP-I disorder.

Attention-deficit hyperactivity disorder and anxiety disorders as precursors of bipolar disorder onset in adulthood

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) and anxiety disorders have been proposed as precursors of bipolar disorder, but their joint and relative roles in the development of bipolar disorder are unknown.AimsTo test the prospective relationship of ADHD and anxiety with onset of bipolar disorder.

METHOD

We examined the relationship between ADHD, anxiety disorders and bipolar disorder in a birth cohort of 2 409 236 individuals born in Denmark between 1955 and 1991. Individuals were followed from their sixteenth birthday or from January 1995 to their first clinical contact for bipolar disorder or until December 2012. We calculated incidence rates per 10 000 person-years and tested the effects of prior diagnoses on the risk of bipolar disorder in survival models.

RESULTS

Over 37 394 865 person-years follow-up, 9250 onsets of bipolar disorder occurred. The incidence rate of bipolar disorder was 2.17 (95% CI 2.12-2.19) in individuals with no prior diagnosis of ADHD or anxiety, 23.86 (95% CI 19.98-27.75) in individuals with a prior diagnosis of ADHD only, 26.05 (95% CI 24.47-27.62) in individuals with a prior diagnosis of anxiety only and 66.16 (95% CI 44.83-87.47) in those with prior diagnoses of both ADHD and anxiety. The combination of ADHD and anxiety increased the risk of bipolar disorder 30-fold (95% CI 21.66-41.40) compared with those with no prior ADHD or anxiety.

CONCLUSIONS

Early manifestations of both internalising and externalising psychopathology indicate liability to bipolar disorder. The combination of ADHD and anxiety is associated with a very high risk of bipolar disorder.Declaration of interestNone.

Evaluation of the Strengths and Difficulties Questionnaire-Dysregulation Profile (SDQ-DP)

The Dysregulation Profile (DP) has emerged as a measure of concurrent affective, behavioral and cognitive dysregulation, associated with severe psychopathology, and poor adjustment. While originally developed with the Child Behavior Checklist, more recently the DP has also been defined on the Strengths and Difficulties Questionnaire (SDQ), mostly with a 5-item, but also a 15-item, SDQ-DP measure. This study evaluated the SDQ-DP by examining its factor structure, measurement invariance, and construct validity. Different SDQ-DP operationalizations were compared. In a United States longitudinal community sample (N = 768), a bifactor model consisting of a general Dysregulation factor and three specific factors of Emotional Symptoms, Conduct Problems, and Hyperactivity-Inattention fitted best, across three different developmental periods (early childhood, middle childhood, and adolescence) and across three different reporters (parents, teachers, and youth). Measurement invariance across reporter, gender, and developmental period was demonstrated. These findings indicate that the SDQ-DP, like the CBCL-DP, reflects a broad syndrome of dysregulation that exists in addition to specific syndromes of emotional symptoms, conduct problems, and hyperactivity-inattention. SDQ-DP bifactor scores were strongly related with scores on the 5- and 15-item SDQ-DP measures and similarly concurrently associated with two markers of self-regulation, ego-resiliency and effortful control, and longitudinally with antisocial behavior and disciplinary measures. As reliability, validity, and stability was weaker for the SDQ-DP 5-item measure, use of all 15 items is recommended. Advantages of using a bifactor approach are discussed as well as the potential of the SDQ-DP as an easy screening measure of children at risk for developing serious psychopathology. (PsycINFO Database Record

Dysregulation in children: Origins and implications from age 5 to age 28

Research shows that childhood dysregulation is associated with later psychiatric disorders. It does not yet resolve discrepancies in the operationalization of dysregulation. It is also far from settled on the origins and implications of individual differences in dysregulation. This study tested several operational definitions of dysregulation using Achenbach attention, anxious/depressed, and aggression subscales. Individual growth curves of dysregulation were computed, and predictors of growth differences were considered. The study also compared the predictive utility of the dysregulation indexes to standard externalizing and internalizing indexes. Dysregulation was indexed annually for 24 years in a community sample (n = 585). Hierarchical linear models considered changes in dysregulation in relation to possible influences from parenting, family stress, child temperament, language, and peer relations. In a test of the meaning of dysregulation, it was related to functional and psychiatric outcomes in adulthood. Dysregulation predictions were further compared to those of the more standard internalizing and externalizing indexes. Growth curve analyses showed strong stability of dysregulation. Initial levels of dysregulation were predicted by temperamental resistance to control, and change in dysregulation was predicted by poor language ability and peer relations. Dysregulation and externalizing problems were associated with negative adult outcomes to a similar extent.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research

OBJECTIVES

Over the past two decades, there has been tremendous growth in research regarding bipolar disorder (BD) among children and adolescents (ie, pediatric BD [PBD]). The primary purpose of this article is to distill the extant literature, dispel myths or exaggerated assertions in the field, and disseminate clinically relevant findings.

METHODS

An international group of experts completed a selective review of the literature, emphasizing areas of consensus, identifying limitations and gaps in the literature, and highlighting future directions to mitigate these gaps.

RESULTS

Substantial, and increasingly international, research has accumulated regarding the phenomenology, differential diagnosis, course, treatment, and neurobiology of PBD. Prior division around the role of irritability and of screening tools in diagnosis has largely abated. Gold-standard pharmacologic trials inform treatment of manic/mixed episodes, whereas fewer data address bipolar depression and maintenance/continuation treatment. Adjunctive psychosocial treatment provides a forum for psychoeducation and targets primarily depressive symptoms. Numerous neurocognitive and neuroimaging studies, and increasing peripheral biomarker studies, largely converge with prior findings from adults with BD.

CONCLUSIONS

As data have accumulated and controversy has dissipated, the field has moved past existential questions about PBD toward defining and pursuing pressing clinical and scientific priorities that remain. The overall body of evidence supports the position that perceptions about marked international (US vs elsewhere) and developmental (pediatric vs adult) differences have been overstated, although additional research on these topics is warranted. Traction toward improved outcomes will be supported by continued emphasis on pathophysiology and novel therapeutics.

Clinical features and subjective/physiological responses to emotional stimuli in the presence of emotion dysregulation in attention-deficit hyperactivity disorder

INTRODUCTION

Emotion dysregulation (ED) has long been recognized in clinical descriptions of attention-deficit hyperactivity disorder (ADHD), but a renewed interest in ED has advanced research on the overlap between the two entities. Autonomic reactivity (AR) is a neurobiological correlate of emotion regulation; however, the association between ADHD and AR remains unclear. Our aim was to explore the clinical differences, AR, and subjective emotional responses to visual emotional stimuli in ADHD children with and without ED.

METHOD

School-aged ADHD children with (n = 28) and without (n = 20) ED, according to the definition of deficiency in emotional self-regulation (DESR), and healthy controls (n = 22) were interviewed by using the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime version (K-SADS-PL) to screen frequent psychopathologies for these ages. All subjects were evaluated with Child Behavior Checklist 6-18 (CBCL), the Strengths and Difficulties Questionnaire (SDQ), the McMaster Family Assessment Device (FAD), the School-Age Temperament Inventory (SATI), and Conners' Parent Rating Scale (CPRS-48), which were completed by parents. To evaluate emotional responses, the International Affective Picture System (IAPS) and the subjective and physiological responses (electrodermal activity and heart rate reactivity) to selected pictures were examined.

RESULTS

Regarding clinically distinctive features, the ADHD+ED group differed from the ADHD-ED and the control groups in terms of having higher temperamental negative reactivity, more oppositional/conduct problems, and lower prosocial behaviors. In the AR measures, children in the ADHD+ED group rated unpleasant stimuli as more negative, but they still had lower heart rate reactivity (HRR) than the ADHD-ED and control groups; moreover, unlike the two other groups, the ADHD+ED group showed no differences in HRR between different emotional stimuli.

CONCLUSION

The presented findings are unique in terms of their ability to clinically and physiologically differentiate between ADHD children with and without ED.

Normative development of the Child Behavior Checklist Dysregulation Profile from early childhood to adolescence: Associations with personality pathology

The Dysregulation Profile (DP) is a broad indicator of concurrent affective, behavioral, and cognitive dysregulation, often measured with the anxious/depressed, aggressive behavior, and attention problems syndrome scales of the Child Behavior Checklist. Despite an expanding body of research on the DP, knowledge of the normative developmental course of the DP from early childhood to adolescence is lacking. Furthermore, although we know that the DP longitudinally predicts personality pathology, no research yet has examined whether next to the DP in early childhood, the rate of change of the DP across development predicts personality pathology. Therefore, using cohort-sequential latent growth modeling in a population-based sample (N = 668), we examined the normative developmental course of mother-reported DP from ages 4 to 17 years and its associations with a wide range of adolescent-reported personality pathology dimensions 3 years later. The results showed that the DP follows a nonlinear developmental course with a peak in early adolescence. The initial level of the DP at age 4 and, to a lesser extent, the rate of change in the DP predicted a range of personality pathology dimensions in late adolescence. The findings suggest that the DP is a broad developmental precursor of personality pathology in late adolescence.

Effect of Methylphenidate on Emotional Dysregulation in Children With Attention-Deficit/Hyperactivity Disorder + Oppositional Defiant Disorder/Conduct Disorder

BACKGROUND AND AIM

Emotional dysregulation (ED) is a frequent feature of attention-deficit/hyperactivity disorder (ADHD). It can be observed as a dysregulation profile or a deficient emotional self-regulation (DESR) profile. Oppositional defiant disorder/conduct disorder (ODD/CD) comorbidity is prevalent in ADHD and known to be related with ED. The first-line treatment of ADHD includes psychostimulants, but their effects on ED are not well studied. This study aimed to evaluate the outcomes of methylphenidate (MPH) treatment on ED in ADHD + ODD/CD cases.

METHODS

A total of 118 ADHD + ODD/CD patients with a mean age of 9.0 ± 1.9 years were treated with MPH for 1 year. Also, parents of cases were recruited for a parent-training program, which initiated after first month of MPH treatment. Symptom severity was assessed at baseline and 12th month by Turgay Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Based Child and Adolescent Behavior Disorders Screening and Rating Scale-Parent Form, Children Depression Inventory, Child Behavior Checklist 4-18 years, and Parental Acceptance and Rejection Questionnaire-Mother Form.

RESULTS

Emotional dysregulation (DESR + DP) was present in 85.6% of cases. Conduct disorder was significantly higher in patients with DP, whereas ODD was significantly higher in the DESR and non-ED groups (P < 0.0001). Symptoms of ADHD and ED were significantly improved with 1-year of MPH treatment (P < 0.05). The improvement in ED was independent of improvement in ADHD symptoms and parent training (P < 0.05).

CONCLUSIONS

Emotional dysregulation is highly prevalent in disruptive behavioral disorders as ODD and CD, which are comorbid with ADHD. The MPH treatment is effective on ED independently from other clinical determinants.

Comparing the CASI-4R and the PGBI-10 M for Differentiating Bipolar Spectrum Disorders from Other Outpatient Diagnoses in Youth

We compared 2 rating scales with different manic symptom items on diagnostic accuracy for detecting pediatric bipolar spectrum disorder (BPSDs) in outpatient mental health clinics. Participants were 681 parents/guardians of eligible children (465 male, mean age = 9.34) who completed the Parent General Behavior Inventory-10-item Mania (PGBI-10 M) and mania subscale of the Child and Adolescent Symptom Inventory-Revised (CASI-4R). Diagnoses were based on KSADS interviews with parent and youth. Receiver operating characteristic (ROC) analyses and diagnostic likelihood ratios (DLRs) determined discriminative validity and provided clinical utility, respectively. Logistic regressions tested for incremental validity in the CASI-4R mania subscale and PGBI-10 M in predicting youth BPSD status above and beyond demographic and common diagnostic comorbidities. Both CASI-4R and PGBI-10 M scales significantly distinguished BPSD (N = 160) from other disorders (CASI-4R: Area under curve (AUC) = .80, p < 0.0005; PGBI-10 M: AUC = 0.79, p < 0.0005) even though scale items differed. Both scales performed equally well in differentiating BPSDs (Venkatraman test p > 0.05). Diagnostic likelihood ratios indicated low scores on either scale (CASI: 0-5; PGBI-10 M: 0-6) cut BPSD odds to 1/5 of those with high scores (CASI DLR- = 0.17; PGBI-10 M DLR- = 0.18). High scores on either scale (CASI: 14+; PGBI-10 M: 20+) increased BPSD odds about fourfold (CASI DLR+ = 4.53; PGBI-10 M DLR+ = 3.97). Logistic regressions indicated the CASI-4R mania subscale and PGBI-10 M each provided incremental validity in predicting youth BPSD status. The CASI-4R is at least as valid as the PGBI-10 M to help identify BPSDs, and can be considered as part of an assessment battery to screen for pediatric BPSDs.

Ability of the Child Behavior Checklist-Dysregulation Profile and the Youth Self Report-Dysregulation Profile to identify serious psychopathology and association with correlated problems in high-risk children and adolescents

BACKGROUND

The current analyses examined whether the dysregulation profile (DP) 1) could be used to identify children and adolescents at high risk for complex and serious psychopathology and 2) was correlated to other emotional and behavioral problems (such as delinquent behavior or suicide ideation). DP was assessed using both the Child Behavior Checklist (CBCL) and the Youth Self Report (YSR) in a residential care sample.

METHODS

Children and adolescents (N=374) aged 10-18 years living in residential care in Switzerland completed the YSR, and their professional caregivers completed the CBCL. Participants meeting criteria for DP (T-score ≥67 on the anxious/‌depressed, attention problems, and aggressive behavior scales of the YSR/CBCL) were compared against those who did not for the presence of complex psychopathology (defined as the presence of both emotional and behavioral disorders), and also for the prevalence of several psychiatric diagnoses, suicidal ideation, traumatic experiences, delinquent behaviors, and problems related to quality of life.

RESULTS

The diagnostic criteria for CBCL-DP and YSR-DP were met by just 44 (11.8%) and 25 (6.7%) of participants. Only eight participants (2.1%) met the criteria on both instruments. Further analyses were conducted separately for the CBCL-DP and YSR-DP groups. DP was associated with complex psychopathology in only 34.4% of cases according to CBCL and in 60% of cases according to YSR. YSR-DP was somewhat more likely to be associated with psychiatric disorders and associated problems than was the CBCL-DP.

LIMITATIONS

Because of the relatively small overlap between the CBCL-DP and YSR-DP, analyses were conducted largely with different samples, likely contributing to the different results.

CONCLUSIONS

Despite a high rate of psychopathology in the population studied, both the YSR-DP and the CBCL-DP were able to detect only a small proportion of those with complex psychiatric disorders. This result questions the validity of YSR-DP and the CBCL-DP in detecting subjects with complex and serious psychopathology. It is possible that different screening instruments may be more effective.

Child behavior checklist profiles in adolescents with bipolar and depressive disorders

OBJECTIVE

We aimed to evaluate the Child Behavior Checklist (CBCL) profiles in youths with bipolar and depressive disorders.

METHODS

Seventy-four subjects with a mean age of 14.9±1.6years (36 boys) with mood disorders and their parents were recruited from September 2011 to June 2013 in the Department of Psychiatry, Asan Medical Center, Seoul, Korea. Diagnosis of mood disorder and comorbid psychiatric disorder was confirmed by child psychiatrists using the Schedule for Affective Disorders and Schizophrenia for School Age Children - Present and Lifetime version (K-SADS-PL). The parents of the subjects completed the Parent General Behavior Inventory-10-item Mania Scale (P-GBI-10M), Parent-version of Mood Disorder Questionnaire (P-MDQ), ADHD rating scale (ARS) and CBCL. The adolescents completed the 76-item Adolescent General Behavior Inventory (A-GBI), Beck Depression Inventory (BDI), and Adolescent-version of Mood Disorder Questionnaire (A-MDQ).

RESULTS

When adjusted for gender and the comorbidity with ADHD, the Withdrawn and Anxious/Depressed subscale scores of the CBCL were higher in subjects with bipolar disorder than in those with depressive disorder. Higher scores of A-GBI Depressive subscale, A-MDQ and BDI were shown in subjects with bipolar disorder than in those with depressive disorder. There was no significant difference on CBCL-DP, P-GBI-10M, P-MDQ, A-GBI Hypomanic/Biphasic subscale and ARS between two groups. All eight subscales of the CBCL positively correlated with the P-GBI-10M and P-MDQ scores, and seven of all eight subscales of the CBCL positively correlated with A-GBI Depressive and Hypomanic/Biphasic subscales. The BDI score was positively associated with the Withdrawn, Somatic Complaints, Anxious/Depressed, and Social Problems subscale scores. CBCL-DP score was strongly correlated with manic/hypomanic symptoms measured by P-GBI-10M and P-MDQ (r=0.771 and 0.826).

CONCLUSIONS

This study suggests that the CBCL could be used for measuring mood symptoms and combined psychopathology, especially internalizing symptoms, in youth with mood disorder. However, CBCL-DP had limited ability to differentiate bipolar from depressive disorder, at least in adolescents.

Dysregulation in Youth with Anxiety Disorders: Relationship to Acute and 7- to 19- Year Follow-Up Outcomes of Cognitive-Behavioral Therapy

This study evaluated the impact of dysregulation across cognitive, affective, and behavioral domains on acute and 7- to 19-year follow-up outcomes of cognitive-behavioral therapy (CBT) for anxiety, and explored dysregulation as a predictor of psychopathology and impairment in young adulthood among individuals who received anxiety treatment as youth. Participants (N = 64; 50 % female, 83 % non-Hispanic White) from two randomized clinical trials completed a follow-up assessment 7-19 years later. Latent profile analysis identified dysregulation based on Anxious/Depressed, Attention Problems, and Aggressive Behavior scores on the Child Behavior Checklist. Although pretreatment dysregulation was not related to acute or follow-up outcomes for anxiety diagnoses that were the focus of treatment, dysregulation predicted an array of non-targeted psychopathology at follow-up. Among youth with a principal anxiety disorder, the effects of CBT (Coping Cat) appear to be robust against broad impairments in self-regulation. However, youth with a pretreatment dysregulation profile likely need follow-up to monitor for the emergence of other disorders.

Disruptive mood dysregulation disorder: current insights

Disruptive mood dysregulation disorder (DMDD) was introduced as a new diagnostic entity under the category of depressive disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It was included in DSM-5 primarily to address concerns about the misdiagnosis and consequent overtreatment of bipolar disorder in children and adolescents. DMDD does provide a home for a large percentage of referred children with severe persistent irritability that did not fit well into any DSM, Fourth Edition (DSM-IV) diagnostic category. However, it has been a controversial addition to the DSM-5 due to lack of published validity studies, leading to questions about its validity as a distinct disorder. In this article, the authors discuss the diagnostic criteria, assessment, epidemiology, criticism of the diagnosis, and pathophysiology, as well as treatment and future directions for DMDD. They also review the literature on severe mood dysregulation, as described by the National Institute of Mental Health, as the scientific support for DMDD is based primarily on studies of severe mood dysregulation.

The Dysregulation Profile in middle childhood and adolescence across reporters: factor structure, measurement invariance, and links with self-harm and suicidal ideation

Recently, a phenotype of severe dysregulation, the Dysregulation Profile (DP), has been identified. DP consists of elevated scores on the Anxious/Depressed (AD), Aggressive Behavior (AGG) and Attention Problems (AP) scales of the Child Behavior Checklist (CBCL), Teacher Report Form (TRF), or Youth Self Report (YSR). A drawback in current research is that DP has been conceptualized and operationalized in different manners and research on the factor structure of DP is lacking. Therefore, we examined the factor structure of DP across multiple reporters, measurement invariance across gender, parents, and time, as well as links between DP and self-harm and suicidal ideation. Data from a large community sample were used (N = 697), covering middle childhood (Mage = 7.90, (SD = 1.16) and adolescence (Mage = 13.93, SD = 1.14). Mothers, fathers, teachers, and youth themselves reported on children's emotional and behavioral problems using the CBCL, TRF, and YSR. Results indicated that in middle childhood and in adolescence, a bifactor model with a general factor of Dysregulation alongside three specific factors of AD, AGG, and AP fitted best, compared to a second-order or one-factor model. The model showed good fit for mother, father, teacher, and youth reports and showed invariance across gender, parents and time. Youth, mother, and father reported Dysregulation was uniquely and positively related to adolescent-reported self-harm and suicidal ideation. The DP is best conceptualized as a broad dysregulation syndrome, which exists over and above anxiety/depression, aggression, and attention problems as specific problems. The bifactor model of DP explains the uniqueness and interrelatedness of these behavioral problems and can help explaining shared and non-shared etiology factors. The exclusive link between the general dysregulation factor and adolescents' self-harm and suicidal ideation further established the clinical relevance of the bifactor model.

Child behavior checklist dysregulation profile in children with disruptive behavior disorders: A longitudinal study

BACKGROUND

A Child Behavior Checklist (CBCL) profile defined as Dysregulation Profile (DP) (scores 2 standard deviations or more in anxiety/depression, aggression, attention subscales) has been correlated to poor emotional and behavioral self-regulation. The clinical meaning and the prognostic implications of CBCL-DP are still debated, although it seems associated with severe psychopathology and poor adjustment.

METHOD

In the present study, we used the CBCL-DP score to examine the adolescent outcomes (psychiatric diagnosis, substance use, psychiatric hospitalization) in 80 referred children with disruptive behavior disorders -DBD- (Oppositional Defiant Disorder or conduct disorder), aged 8-9 years, 72 males (90%) and 8 females (10%), followed-up until the age of 14-15 years.

RESULTS

Children with higher score on the CBCL-DP profile were at increased risk for presenting ADHD and mood disorders in adolescence. While ADHD in adolescence was predicted also by an ADHD diagnosis during childhood, CBCL-DP score was the only significant predictor of a mood disorder at 14-15 years. On the contrary, CBCL-DP score was not associated with a higher risk of conduct disorder, substance use and hospitalizations in adolescence. A cost-effective and reliable diagnostic measure such as the CBCL may be a part of the diagnostic procedure aimed to capture these at-risk children, to monitor their natural history up to adolescence, and to prevent the risk of a full-blown mood disorder.

LIMITATIONS

The small sample size and a selection bias of severe patients with DBD limit the generalization of the findings.

Antecedents of the child behavior checklist-dysregulation profile in children born extremely preterm

OBJECTIVE

Extremely preterm newborns are at heightened risk for emotional and behavioral dysregulation later in childhood. Our goal was to systematically evaluate the antenatal and early postnatal antecedents that might mediate the association between extreme preterm birth and emotional and behavioral dysregulation at age 2 years (corrected age).

METHOD

In a multi-site prospective study, the parents of 826 infants born before 28 weeks gestation completed a Child Behavior Checklist (CBCL) when the child was 2 years corrected age. We compared the maternal, pregnancy, placenta, delivery, and newborn characteristics, as well as early postnatal characteristics and exposures of those who satisfied criteria for the CBCL-Dysregulation Profile (CBCL-DP) to those of their peers. We then used time-oriented logistic regression models, starting first with antenatal variables that distinguished children with the CBCL-DP profile from their peers, and then added the distinguishing postnatal variables.

RESULTS

Approximately 9% of the children had a CBCL-DP. In the time-oriented logistic regression model with antenatal variables only, low maternal education achievement, passive smoking, and recovery of Mycoplasma from the placenta were associated with increased risk, whereas histologic chorioamnionitis was associated with reduced risk. None of the postnatal variables added statistically significant discriminating information.

CONCLUSION

Very preterm newborns who later manifest the CBCL-DP at age 2 years differ in multiple ways from their preterm peers who do not develop the CBCL-DP, raising the possibility that potentially modifiable antenatal and early postnatal phenomena contribute to the risk of developing emotional and behavioral dysregulation.

Bipolar disorder and ADHD: comorbidity and diagnostic distinctions

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) are neurodevelopmental disorders with onset in childhood and early adolescence, and common persistence in adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed, leading to high rates of morbidity and disability. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history course of illness, and response to treatment. We review recent relevant findings and highlight epidemiological, clinical, family history, course, and treatment-response differences that can aid the differential diagnosis of these conditions in an outpatient pediatric setting.

The Child Behavior Checklist Dysregulation Profile in Preschool Children: A Broad Dysregulation Syndrome

OBJECTIVE

Children with concurrent impairments in regulating affect, behavior, and cognition can be identified with the Anxious/Depressed, Aggressive Behavior, and Attention Problems scales (or AAA scales) of the Child Behavior Checklist (CBCL). Jointly, these scales form the Dysregulation Profile (DP). Despite persuasive evidence that DP is a marker for severe developmental problems, no consensus exists on the preferred conceptualization and operationalization of DP in preschool years. We addressed this concern by testing and validating the factor structure of DP in a group of predominantly clinically referred preschool children.

METHOD

Participants were 247 children (195 boys and 52 girls), aged 3.5 to 5.5 years. Children were assessed at baseline and 18 months later, using parent and teacher reports, a clinical interview with parents, behavioral observations, and neuropsychological tasks.

RESULTS

Confirmatory factor analysis showed that a bifactor model, with a general DP factor and 3 specific factors representing the AAA scales, fitted the data better than a second-order model and a one-factor model for both parent-reported and teacher-reported child problem behavior. Criterion validity analyses showed that the DP factor was concurrently and longitudinally associated with markers of dysregulation and clinically relevant criteria, whereas the specific factors representing the AAA scales were more differentially related to those criteria.

CONCLUSION

DP is best conceptualized as a broad syndrome of dysregulation that exists in addition to the specific syndromes as represented by the AAA scales. Implications for researchers and clinicians are discussed.

Stress in parents of children born very preterm is predicted by child externalising behaviour and parent coping at age 7 years

OBJECTIVE

To examine factors which predict parenting stress in a longitudinal cohort of children born very preterm, and seen at age 7 years.

METHODS

We recruited 100 very preterm (≤32 weeks gestational age) child-parent dyads and a control group of 50 term-born dyads born between 2001 and 2004 with follow-up at 7 years. Parents completed the Parenting Stress Index, Ways of Coping Questionnaire, Child Behavior Check List, Beck Depression Inventory and the State Trait Anxiety Inventory questionnaires. Child IQ was assessed using the Wechsler Intelligence Scale-IV.

RESULTS

After controlling for maternal education, parents of preterm children (95% CI 111.1 to 121.4) scored higher (p=0.027) on the Parenting Stress Index than term-born controls (95% CI 97.8 to 113.2). Regression analyses showed that child externalising behaviour, sex and parent escape/avoidance coping style, predicted higher parenting stress in the preterm group. Parents of preterm girls expressed higher levels of stress than those of boys.

CONCLUSIONS

Maladaptive coping strategies contribute to greater stress in parents of very preterm children. Our findings suggest that these parents need support for many years after birth of a very preterm infant.

Family material hardship and chinese adolescents' problem behaviors: a moderated mediation analysis

In the current study, we examined a moderated mediation model using the risk and resilience framework. Specifically, the impact of family material hardship on adolescent problem behaviors was examined in a Chinese sample; we used the family stress model framework to investigate parental depression and negative parenting as potential mediators of the relation between family material hardship and adolescents' problem behaviors. In addition, based on resilience theory, we investigated adolescents' resilience as a potential protective factor in the development of their internalizing and externalizing problems. Participants included 1,419 Chinese adolescents (mean age = 15.38 years, SD = 1.79) and their primary caregivers. After controlling for covariates (age, gender, location of family residence, and primary caregiver), we found that parental depression and negative parenting mediated the association between family material hardship and adolescents' problem behaviors. Furthermore, the adolescent resilience moderated the relationship between negative parenting and internalizing problems in a protective-stabilizing pattern; in addition, a protective-reactive pattern also emerged when adolescent resilience was examined as a moderator of the relationship between negative parenting and externalizing problems. These findings contribute to a comprehensive understanding of the mechanisms of risk and resilience in youth development. Moreover, the findings have important implications for the prevention of adolescent problem behaviors.

Psychosocial interventions in the treatment of youth diagnosed or at high-risk for pediatric bipolar disorder: A review of the literature

Pediatric bipolar disorder (PBD) has emerged as a research field in which psychosocial treatments have provided a plethora of empirical findings over the last decade. We addressed this issue through a systematic review aimed of establishing their effectiveness and feasibility as adjunctive therapies for youth with PBD or at high-risk for PBD. A comprehensive search of databases was performed between 1990 and September 2014. Overall, 33 studies were specifically related to the issue and 20 of them were original articles. Evidence suggests that both "multi-family psychoeducational psychotherapy' and "family-focused therapy" are possible effective treatments for PBD. Likewise, "child and family-focused cognitive-behavioral therapy" may be characterized as a treatment in its experimental phase. The remaining therapies fail to obtain enough empirical support due to inconsistent findings among clinical trials or data solely based on case reports. Studies of psychosocial treatments provide concluding results concerning their feasibility and acceptability. Larger sample sizes and more randomized controlled trials are mandatory for diminishing methodological shortcomings encountered in the treatments displayed.

Do ADHD children with and without child behavior checklist-dysregulation profile have different clinical characteristics, cognitive features, and treatment outcomes?

OBJECTIVE

The Child Behavior Checklist-Dysregulation Profile (CBCL-DP), characterized by elevated scores on the "Attention Problems," "Aggressive Behavior," and "Anxious/Depressed" scales in the CBCL, has been associated with later severe psychopathology. In a sample of children with ADHD, this study sought to further explore the clinical characteristics, the response to methylphenidate medication, and the cognitive features of ADHD children with CBCL-DP.

METHOD

The sample consisted of 173 ADHD outpatients (age = 10.9 ± 2.81) assessed using symptom severity scales, personality questionnaires (Emotionality Activity Sociability [EAS] and Junior Temperament and Character Inventory [JTCI]), and neuropsychological tests. A subsample of 136 participants was reassessed after optimal adjustment of methylphenidate dosage.

RESULTS AND CONCLUSION

Variables that were independently associated with CBCL-DP were clinical severity (ADHD Rating Scale [ADHD-RS]), internalized disorders, high emotionality (EAS), and low self-directedness (JTCI). CBCL-DP was associated neither with poorer response to methylphenidate nor with more side effects. There were no differences in cognitive performances between participants with and without CBCL-DP.

DSM-5: disruptive mood dysregulation disorder

This paper will describe historical perspectives for the introduction of disruptive mood dysregulation disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), criteria for the diagnosis, as well as information on epidemiology, clinical presentation and longitudinal course, pathophysiology, and treatment. The diagnosis of disruptive mood dysregulation disorder requires frequent, persistent, severe temper outbursts out of proportion to the situation and developmental context in combination with persistent, angry/irritable mood between the temper outbursts. Because of the limited available data, the inclusion of this new diagnosis in DSM-5 has been controversial. Regardless of this controversy, it is clear that youth experiencing such symptoms are highly impaired and utilize significant health services. Therefore, we need to expand our efforts to better understand the complex construct of this phenotype in order to improve the assessment, diagnosis and treatment of this condition.

The Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P): description and validation in a psychiatric sample and healthy controls

OBJECTIVE

The aim of the present study was to investigate the psychometric properties of the Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P), the first specific interview for emerging bipolar disorder (BD) symptoms.

METHODS

A total of 205 youth aged 12-23 years and/or their caregivers underwent BPSS-P interviews: 129 patients with mood spectrum disorders [depression spectrum disorder (n = 77), mood disorder not otherwise specified (NOS) (n = 27), BD-NOS (n = 14), bipolar I disorder (BD-I)/bipolar II disorder (BD-II)/cyclothymia (n = 11), 34 with non-mood spectrum disorders, and 42 healthy controls (HCs)]. We used Cronbach's α to assess internal consistency; intra-class correlation (ICC) for inter-rater reliability; Spearman's rho for convergent validity with the Young Mania Rating Scale (YMRS), General Behavior Inventory-10-item Mania Form (GBI-M-10), and Cyclothymic-Hypersensitive Temperament (CHT) scale; and analysis of variance for discriminatory power between diagnostic groups.

RESULTS

Internal consistency was good to very good for the BPSS-P Mania (Cronbach's α = 0.87), Depression (Cronbach's α = 0.89), and General Symptom indices (Cronbach's α = 0.74). Inter-rater reliability was high for the BPSS-P Total score (ICC = 0.939), and BPSS-P Mania (ICC = 0.934), Depression (ICC = 0.985), and General (ICC = 0.981) indices. Convergent validity was large (ρ ≥ 0.50) between the BPSS-P Mania Index and YMRS, GBI-M-10, and CHT; BPSS-P Depression Index and Montgomery-Åsberg Depression Rating Scale (MADRS) and CHT; and BPSS-P General Index and GBI-M-10 and CHT. Expectedly, convergent validity was small (ρ = 0.10 to < 0.30) between the BPSS-P Mania Index and MADRS, and BPSS-P Depression Index and YMRS. Furthermore, the BPSS-P and its subscales discriminated each patient group from HCs and from non-mood spectrum patients (except for the BPSS-P General Index). Moreover, the BPSS-P Total score discriminated BD-I/BD-II/cyclothymia from depression spectrum patients, and the BPSS-Mania Index differentiated all three bipolar spectrum groups from depression spectrum patients.

CONCLUSIONS

The BPSS-P has good to excellent psychometric properties. Its use across multiple settings and predictive validity requires further investigation.

Disruptive mood dysregulation disorder and chronic irritability in youth at familial risk for bipolar disorder

OBJECTIVE

Disruptive mood dysregulation disorder (DMDD) is a new diagnosis in the DSM-5. Youth with a family history of bipolar disorder (BD) are at increased risk for BD and non-bipolar psychopathology. No studies to date have examined rates of DMDD among offspring of parents with BD. This study examines the risk for DMDD in offspring of parents with BD compared to community controls and considers rates of chronic irritability (independent of a DMDD diagnosis) across diagnoses in youth with parents with BD.

METHOD

Modified DMDD criteria were applied post hoc to 375 offspring of parents with BD and 241 offspring, aged 6 to 17 years, of community control parents. We calculated odds ratios using generalized linear mixed models. In addition, we explored associations with a severe chronic irritability phenotype and various diagnoses in the high-risk cohort.

RESULTS

Offspring of parents with BD were more likely to meet criteria for DMDD than were the offspring of community control parents (Odds ratio [OR] = 8.3, 6.7% vs. 0.8%), even when controlling for demographic variables and comorbid parental diagnoses (OR = 5.4). They also had higher rates of chronic irritability compared to community controls (12.5% vs. 2.5%, χ(2) = 18.8, p < .005). Within the offspring of parents with BD, the chronic irritability phenotype was frequently present in offspring with diagnoses of BD, depression, attention-deficit/hyperactivity disorder, and disruptive behavior disorders.

CONCLUSIONS

Like other non-BD diagnoses, family history of BD increases the risk for DMDD. Severe chronic irritability and temper tantrums are the core features of DMDD, and are associated with mood and behavioral disorders in youth at risk for BD.

The CBCL dysregulated profile: an indicator of pediatric bipolar disorder or of psychopathology severity?

BACKGROUND

To evaluate whether the Child Behavior Checklist Dysregulated Profile (CBCL-DP) can be used as an effective predictor of psychopathological severity as indicated by suicidality and comorbidities, as well as a predictor of pediatric bipolar disorder (PBD).

METHOD

CBCL-DP scores for 397 youths seeking treatment for mood disorders were calculated by summing the t-scores of the Anxious/Depressed, Aggressive Behaviors, and Attention Problems subscales such that a clinical cut-off of 210 was used to indicate the presence of a dysregulated profile. Suicidality and an increased number of diagnoses were used as markers of illness severity.

RESULTS

Those with a dysregulated profile presented more severe suicidal ideation when compared to those without the profile. They also had a significantly larger number of Axis I diagnoses. Groups did not differ in the amount of individuals diagnosed with PBD.

LIMITATIONS

Suicidal ideation was assessed by a third-party informant and not from the youths themselves. No other forms of suicidal behavior such as self-harm or suicide attempt were measured. Also there may not be complete convergence between parental reports on behavior and youth reports, which might have affected the results.

CONCLUSIONS

These findings suggest that the CBCL-DP is an effective indicator of psychopathological severity through its association with more comorbidities and more severe suicidality. Earlier detection of psychopathological severity through an initial screening tool could aid clinicians in planning treatment and providing quicker and more structured care based on the client's needs.

Genome-wide association study of proneness to anger

Background

Community samples suggest that approximately 1 in 20 children and adults exhibit clinically significant anger, hostility, and aggression. Individuals with dysregulated emotional control have a greater lifetime burden of psychiatric morbidity, severe impairment in role functioning, and premature mortality due to cardiovascular disease.

Methods

With publically available data secured from dbGaP, we conducted a genome-wide association study of proneness to anger using the Spielberger State-Trait Anger Scale in the Atherosclerosis Risk in Communities (ARIC) study (n = 8,747).

Results

Subjects were, on average, 54 (range 45–64) years old at baseline enrollment, 47% (n = 4,117) were male, and all were of European descent by self-report. The mean Angry Temperament and Angry Reaction scores were 5.8±1.8 and 7.6±2.2. We observed a nominally significant finding (p = 2.9E-08, λ = 1.027 - corrected p_gc = 2.2E-07, λ = 1.0015) on chromosome 6q21 in the gene coding for the non-receptor protein-tyrosine kinase, Fyn.

Conclusions

Fyn interacts with NDMA receptors and inositol-1,4,5-trisphosphate (IP3)-gated channels to regulate calcium influx and intracellular release in the post-synaptic density. These results suggest that signaling pathways regulating intracellular calcium homeostasis, which are relevant to memory, learning, and neuronal survival, may in part underlie the expression of Angry Temperament.

Prevalence and correlates of psychopathology in children and adolescents evaluated with the strengths and difficulties questionnaire dysregulation profile in a clinical setting

BACKGROUND

The clinical presentation of children and adolescents referred to mental health services is frequently complicated by comorbid and severe affective and behavioral dysregulation. This dysregulation phenotype seems to be an indicator of overall psychopathology, symptom severity and functional impairment. Currently, this phenotype is assessed by the Child Behavior Checklist. However, the widely used Strengths and Difficulties Questionnaire (SDQ) has been recently validated to screen the Dysregulation Profile (SDQ-DP) in clinical settings. The objective of this study was to determine the prevalence and demographic, psychosocial and clinical correlates of the SDQ-DP phenotype in a Spanish clinical sample.

SAMPLING AND METHODS

In a clinical sample of 623 consecutively referred children and adolescents (4-17 years old), we compared clinical and sociodemographic correlates between subjects who met the SDQ-DP criteria (DP) and those who did not (NO_DP). Sociodemographic data, parent-rated SDQ, Children's Global Assessment Scale, Clinical Global Impression, family Apgar scale and clinical diagnoses were collected by experienced child and adolescent psychiatrists.

RESULTS

Overall in our sample, 175 subjects (28.1%) met the SDQ-DP criteria (DP group). Compared with the NO_DP group, the DP subjects had significantly higher scores on internalizing and externalizing psychopathology, problems with peers and overall problems as well as significantly lower scores on prosocial behavior. Clinical diagnoses assigned revealed that DP subjects showed significantly greater psychiatric comorbidity. DP subjects also showed significantly worse family functioning and increased symptom severity and significantly lower scores on psychosocial functioning.

CONCLUSIONS

A high prevalence of children and adolescents with the dysregulated profile, assessed by the SDQ-DP, was found in our clinical setting. The SDQ-DP may serve as an index of overall psychological severity and functional impairment. In addition, it may indicate family dysfunction. Further research is needed to validate the clinical value of SDQ-DP by examining longitudinal stability, heritability, adult outcome, risk factors and diagnostic correlates.

Disturbances in reality testing as markers of risk in offspring of parents with bipolar disorder: a systematic review from a developmental psychopathology perspective

OBJECTIVES

This comprehensive review examined the prevalence and progression of disturbances in reality testing (DRT), defined as psychotic symptoms, cognitive disruptions, and thought problems, in offspring of parents with bipolar disorder (O-BD). Our approach was grounded in a developmental psychopathology perspective and considered a broader phenotype of risk within the bipolar-schizophrenia spectrum as measured by categorical and dimensional assessments of DRT in high-risk youth.

METHODS

Relevant studies were identified from numerous sources (e.g., PubMed, reference sections, and colleagues). Inclusion criteria were: (i) family risk studies published between 1975 and 2012 in which O-BD were contrasted with a comparison group (e.g., offspring of parents who had other psychiatric disorders or were healthy) on DRT outcomes and (ii) results reported for categorical or dimensional assessments of DRT (e.g., schizophrenia, psychotic symptoms, cluster A personality traits, or thought problems), yielding a total of 23 studies.

RESULTS

Three key findings emerged: (i) categorical approaches of DRT in O-BD produced low incidence base rates and almost no evidence of significant differences in DRT between O-BD and comparison groups, whereas (ii) many studies using dimensional assessments of DRT yielded significant group differences in DRT. Furthermore, (iii) preliminary evidence from dimensional measures suggested that the developmental progression of DRT in O-BD might represent a prodrome of severe psychological impairment.

CONCLUSIONS

Preliminary but promising evidence suggests that DRT is a probable marker of risk for future impairment in O-BD. Methodological strengths and weaknesses, the psychometric properties of primary DRT constructs, and future directions for developmental and longitudinal research with O-BD are discussed.

Child Behavior Checklist-Mania Scale (CBCL-MS): development and evaluation of a population-based screening scale for bipolar disorder

CONTEXT

Early identification of Bipolar Disorder (BD) remains poor despite the high levels of disability associated with the disorder.

OBJECTIVE

We developed and evaluated a new DSM orientated scale for the identification of young people at risk for BD based on the Child Behavior Checklist (CBCL) and compared its performance against the CBCL-Pediatric Bipolar Disorder (CBCL-PBD) and the CBCL-Externalizing Scale, the two most widely used scales.

METHODS

The new scale, CBCL-Mania Scale (CBCL-MS), comprises 19 CBCL items that directly correspond to operational criteria for mania. We tested the reliability, longitudinal stability and diagnostic accuracy of the CBCL-MS on data from the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective epidemiological cohort study of 2230 Dutch youths assessed with the CBCL at ages 11, 13 and 16. At age 19 lifetime psychiatric diagnoses were ascertained with the Composite International Diagnostic Interview. We compared the predictive ability of the CBCL-MS against the CBCL-Externalising Scale and the CBCL-PBD in the TRAILS sample.

RESULTS

The CBCL-MS had high internal consistency and satisfactory accuracy (area under the curve = 0.64) in this general population sample. Principal Component Analyses, followed by parallel analyses and confirmatory factor analyses, identified four factors corresponding to distractibility/disinhibition, psychosis, increased libido and disrupted sleep. This factor structure remained stable across all assessment ages. Logistic regression analyses showed that the CBCL-MS had significantly higher predictive ability than both the other scales.

CONCLUSIONS

Our data demonstrate that the CBCL-MS is a promising screening instrument for BD. The factor structure of the CBCL-MS showed remarkable temporal stability between late childhood and early adulthood suggesting that it maps on to meaningful developmental dimensions of liability to BD.

The child behavior checklist dysregulation profile predicts adolescent DSM-5 pathological personality traits 4 years later

Emotional dysregulation in childhood has been associated with various forms of later psychopathology, although no studies have investigated the personality related adolescent outcomes associated with early emotional dysregulation. The present study uses a typological approach to examine how the child behavior checklist-dysregulation profile (CBCL-DP) predicts DSM-5 pathological personality traits (as measured with the personality inventory for the diagnostic and statistical manual of mental disorders 5 or PID-5 by Krueger et al. (Psychol Med 2012)) across a time span of 4 years in a sample of 243 children aged 8-14 years (57.2 % girls). The results showed that children assigned to the CBCL-DP class are at risk for elevated scores on a wide range of DSM-5 personality pathology features, including higher scores on hostility, risk taking, deceitfulness, callousness, grandiosity, irresponsibility, impulsivity and manipulativeness. These results are discussed in the context of identifying early manifestations of persistent regulation problems, because of their enduring impact on a child's personality development.

Mood lability among offspring of parents with bipolar disorder and community controls

OBJECTIVES

Early identification of bipolar disorder (BP) symptomatology is crucial for improving the prognosis of this illness. Increased mood lability has been reported in BP. However, mood lability is ubiquitous across psychiatric disorders and may be a marker of severe psychopathology and not specific to BP. To clarify this issue, this study examined the prevalence of mood lability and its components in offspring of BP parents and offspring of community control parents recruited through the Pittsburgh Bipolar Offspring Study.

METHODS

Forty-one school-age BP offspring of 38 BP parents, 257 healthy or non-BP offspring of 174 BP parents, and 192 offspring of 117 control parents completed a scale that was developed to evaluate mood lability in youth, i.e., the Children's Affective Lability Scale (CALS).

RESULTS

A factor analysis of the parental CALS, and in part the child CALS, revealed Irritability, Mania, and Anxiety/Depression factors, with most of the variance explained by the Irritability factor. After adjusting for confounding factors (e.g., parental and offspring non-BP psychopathology), BP offspring of BP parents showed the highest parental and child total and factor scores, followed by the non-BP offspring of BP parents, and then the offspring of the controls.

CONCLUSIONS

Mood lability overall and mania-like, anxious/depressed, and particularly irritability symptoms may be a prodromal phenotype of BP among offspring of parents with BP. Prospective studies are warranted to clarify whether these symptoms will predict the development of BP and/or other psychopathology. If confirmed, these symptoms may become a target of treatment and biological studies before BP develops.

Characteristics of the child behavior checklist in adolescents with depression associated with bipolar disorder

BACKGROUND

The child behavior checklist-Juvenile bipolar disorder phenotype (CBCL-JBD) has been proposed as a distinct profile specific to children and adolescents who have been diagnosed with bipolar disorder. The objective of this study was to examine whether bipolar disorder youth with depression exhibit the "CBCL-Juvenile bipolar disorder phenotype."

METHODS

Thirty-two adolescents, ages 12-18 years, with a depressive episode associated with bipolar I disorder were recruited, and their primary caregivers completed the CBCL.

RESULTS

Only the internalizing subscale (mean=70.2, SD=9.7) and total score (mean=71.5, SD=8.9) reached clinical significance (>70). Moreover, the CBCL-JBD profile scores of our subjects (204.6, SD=27.5) did not reach clinical significance (>210).

LIMITATIONS

Our subjects differed demographically from those in studies that have confirmed the CBCL-Juvenile bipolar disorder phenotype with regards to sex, age and ADHD comorbidity, thus limiting the interpretability of our comparisons with other studies. Furthermore, our investigation involved a small sample size and did not include a control group, which should be addressed in future studies.

CONCLUSIONS

The results of our study suggest that the CBCL-JBD profile is not characteristic of depressed youth with bipolar disorder. Better assessment tools for making an accurate and efficient diagnosis of bipolar disorder are needed so that appropriate treatment can be implemented and significant morbidity and mortality are minimized.

The significance of at-risk or prodromal symptoms for bipolar I disorder in children and adolescents

While in the early identification and intervention of psychosis-specific instruments and risk criteria have been generated and validated, research into indicated preventive strategies for bipolar I disorder (BD I) has only recently gained momentum. As the first signs of BD I often start before adulthood, such efforts are especially important in the vulnerable pediatric population. Data are summarized regarding the presence and nature of potentially prodromal, that is, subsyndromal, symptoms prior to BD I, defined by first-episode mania, focusing on pediatric patients. Research indicates the possibility of early identification of youth at clinical high risk for BD. Support for this proposition comes from retrospective studies of BD I patients, as well as prospective studies of community samples, offspring of BD I subjects, youth with depressive disorders, and patients at high risk for psychosis or with bipolar spectrum disorders without lifetime history of mania. These data provide essential insight into potential signs and symptoms that may enable presyndromal identification of BD I in youth. However, except for offspring studies, broader prospective approaches that focus on youth at clinical high risk for BD I and on developing specific interviews and (or) rating scales and risk criteria are mostly missing, or in their early stage. More work is needed to determine valid and sufficiently specific clinical high-risk criteria, to distinguish risk factors, endophenotypes, and comorbidities from prodromal symptomatology, and to develop phase-specific interventions that titrate the risk of intervention to the risk of transition to mania and to functional impairment or distress. Moreover, studies are needed that determine potential differences in prodromal symptoms and trajectories between children, adolescents, and adults, and the best phase-specific interventions.

Family functioning, social impairment, and symptoms among adolescents with bipolar disorder

OBJECTIVE

Impaired social functioning is common among youth with bipolar disorder (BD), emerges in multiple settings, and persists over time. However, little is known about factors associated with poor peer and family functioning in the early-onset form of BD. Using a sample of adolescents with BD I or II, we examined which symptoms of BD, including nonspecific symptoms such as inattention, aggression, and anxiety/depression, were associated with family functioning (adaptability, cohesion, and conflict) and peer relationship quality.

METHOD

Adolescents (N = 115; 46% male) with BD I and II and their parents were evaluated before participation in a multi-site randomized controlled trial. Adolescents had experienced an episode of depression, mania, or hypomania within the previous 3 months and were not in full remission. Adolescents' problem behaviors were assessed using the parent-rated Child Behavior Checklist (CBCL). Family functioning was assessed via child- and parent-report questionnaires.

RESULTS

Depressive symptoms were associated with lower child-ratings of family functioning. Contrary to hypotheses, moderate mania was associated with better parent-reported family conflict, adaptability, and cohesion. Aggression was associated with poorer family functioning across reporters and measures, even when controlling for the effects of depression, mania, and inattention. None of these symptom clusters were associated with peer functioning.

CONCLUSIONS

Aggression was the strongest correlate of family functioning in pediatric BD in this cross-sectional study. Findings speak to the potential value of addressing aggression and family dysfunction in the treatment of youth with BD. Clinical trial registration information-Effectiveness of Family-Focused Treatment Plus Pharmacotherapy for Bipolar Disorder in Adolescents; http://clinicaltrials.gov/; NCT00332098.

Correlates of the CBCL-dysregulation profile in preschool-aged children

BACKGROUND

A growing literature indicates that the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) identifies youths with heightened risk for severe psychopathology, comorbidity, and impairment. However, this work has focused on school-age children and adolescents; no studies have examined whether preschool-aged children with the CBCL-DP exhibit a similar constellation of problems.

METHOD

Using a community sample of preschoolers, we compared children with (N = 61) and without (N = 488) the CBCL-DP on a broad range of variables assessed using multiple methods.

RESULTS

Univariate analyses revealed numerous differences between children with the CBCL-DP and their peers on psychiatric symptomatology, temperament, parenting behavior, and parental personality, psychopathology, and marital functioning. In multivariate analyses, children with the CBCL-DP exhibited greater temperamental negative affectivity and lower effortful control. They also had more depressive and oppositional defiant symptoms, as well as greater functional impairment. Parents of CBCL-DP children reported engaging in more punitive, controlling parenting behavior than parents of non-profile children.

CONCLUSIONS

In a non-clinical sample of preschoolers, the CBCL-DP is associated with extensive emotional and behavioral dysregulation and maladaptive parenting.

Screening for pediatric bipolar disorder in primary care

A child or adolescent with pediatric bipolar disorder (PBD) is at higher risk for suicide, violence, and impaired psychosocial functioning. The prevalence of diagnosed PBD has increased 40-fold in less than 2 decades, leading some to believe that PBD is inaccurately diagnosed. Complicating this issue, disagreements exist among clinicians as to the utility of current screening methods. The assessment picture is further muddied by the high rate of comorbid psychiatric conditions. A literature review was performed to describe the present understanding of PBD and identify current practices of screening for the disorder. Although screening tools are available, the literature suggests they lack validity. Awareness, a thorough interview, and expedient referral may assist clinicians in making a correct diagnosis. Accurate assessment will help ease the psychological and economic burden of PBD.