Childhood-onset bipolar disorder: Evidence for increased familial loading of psychiatric illness

Familial load of psychiatric disorders and overall functioning in patients newly diagnosed with bipolar disorder and their unaffected first-degree relatives

BACKGROUND

Overall functioning is already impaired in patients newly diagnosed with bipolar disorder (BD) and, to a lesser degree, also in their unaffected first-degree relatives (UR). Further, aggregation of psychiatric disorders among the patients' first-degree relatives seems to be associated with higher illness burden and poorer prognosis. However, whether this aggregation of psychiatric disorders among first-degree relatives, the familial load (FL), impacts overall functioning in patients newly diagnosed with BD and their UR remains unresolved.

METHODS

In total, 388 patients newly diagnosed with BD, 144 of their UR and 201 healthy control individuals were included. Overall functioning was assessed using three different assessment methods: The interviewer based "Functioning Assessment Short Test" (FAST), the questionnaire "Work and Social Adjustment Scale" (WSAS) and six outcome measures covering the participants' socio-economic status (SES); educational achievement, employment, work ability, relationship, cohabitation and marital status. Familial load of psychiatric disorder was assessed using the "Family History Research Diagnostic Criteria" interview. Associations between FL and overall functioning in patients and UR were investigated categorically using logistic and continuously in linear regression models.

RESULTS

Contrasting with the hypotheses, the FL of psychiatric disorders was not associated with impaired overall functioning, neither in patients newly diagnosed with BD nor in their UR.

CONCLUSION

The findings indicate that impaired functioning in the early phase of BD is not associated with aggregation of psychiatric disorders among first-degree relatives. The observed functional impairment in patients newly diagnosed with BD seems driven by the personal impact of the disorder rather than the impact of having first-degree relatives with psychiatric disorders.

Prevalence and correlates of childhood-onset bipolar disorder among adolescents

AIM

Early-onset bipolar disorder (BD) is associated with a more severe illness as well as a number of clinical factors among adults. Early-onset can be categorized as childhood- (age < 13) or adolescent- (age ≥ 13) onset, with the two displaying different clinical profiles. We set out to examine differences in clinical, and familial characteristics among adolescents with childhood- versus adolescent-onset BD.

METHODS

The study included 195 adolescents with BD, ages 14-18 years. Age of onset was determined retrospectively by self-report. Participants completed the semi-structured K-SADS-PL diagnostic interviews along with self-reported dimensional scales. Analyses examined between-group differences for clinical and familial variables. Variables associated with age of onset at p < 0.1 in univariate analyses were evaluated in a logistic regression model.

RESULTS

Approximately one-fifth of participants had childhood-onset BD (n = 35; 17.9%). A number of clinical and familial factors were significantly associated with childhood-onset BD. However, there were no significant differences in depressive and manic symptom severity. In multivariate analyses, the variables most strongly associated with childhood-onset were police contact, and family history of suicidal ideation. Smoking and psychiatric hospitalization were associated with adolescent-onset.

CONCLUSIONS

In this large clinical sample of adolescents with BD, one-fifth reported childhood-onset BD. Correlates of childhood-onset generally aligned with those observed in the literature. Future research is warranted to better understand the genetic and environmental implications of high familial loading of psychopathology associated with childhood-onset, and to integrate age-related treatment and prevention strategies.

Prospectively ascertained mania and hypomania among young adults with child- and adolescent-onset bipolar disorder

OBJECTIVES

While adults with bipolar disorder (BD) often report symptoms starting in childhood, continuity of mania and/or hypomania (mania/hypomania) from childhood to adulthood has been questioned. Using longitudinal data from the Course and Outcome of Bipolar Youth (COBY) study, we assessed threshold mania/hypomania in young adults who manifested BD as youth.

METHODS

COBY is a naturalistic, longitudinal study of 446 youth with BD (84% recruited from outpatient clinics), 7-17 years old at intake, and over 11 years of follow-up. Focusing on youth with BD-I/II (n = 297), we examined adult mania/hypomania risk (>18 years old; mean 7.9 years of follow-up) according to child (<13 years old) versus adolescent (13-17 years old) onset. We next used penalized regression to test demographic and clinical predictors of young adult mania/hypomania.

RESULTS

Most participants (64%) had child-onset mania/hypomania, 57% of whom also experienced mania/hypomania in adolescence. Among those who experienced an episode in adolescence, over 40% also had mania/hypomania during adulthood; the risk did not differ according to child versus adolescent onset. In contrast, 7% with mania/hypomania in childhood, but not adolescence, experienced mania/hypomania in adulthood. Family history (of mania and suicide attempts) predicted mania/hypomania in young adulthood (p-values <0.05); age of onset was not a significant predictor. Among participants with no mania/hypomania during adulthood, 53% (105/198) still experienced subthreshold manic episodes.

DISCUSSION

We find substantial continuity across developmental stage indicating that, in this carefully characterized sample, children who experience mania/hypomania-particularly those who also experience mania/hypomania in adolescence-are likely to experience mania/hypomania in young adulthood.

Examining the relationship between gray matter volume and a continuous measure of bipolarity in unmedicated unipolar and bipolar depression

BACKGROUND

It has been argued that unipolar major depressive disorder (MDD) and bipolar disorder (BD) exist on a continuous spectrum, given their overlapping symptomatology and genetic diatheses. The Bipolarity Index (BI) is a scale that considers bipolarity as a continuous construct and was developed to assess confidence in bipolar diagnosis. Here we investigated whether BI scores correlate with gray matter volume (GMV) in a sample of unmedicated unipolar and bipolar depressed individuals.

METHODS

158 subjects (139 with MDD, 19 with BD) in a major depressive episode at time of scan were assigned BI scores. T1-weighted Magnetic Resonance Imaging scans were obtained and processed with Voxel-Based Morphometry using SPM12 (CAT12 toolbox) to assess GMV. Regression was performed at the voxel level to identify clusters of voxels whose GMV was associated with BI score, (p<0.001, family-wise error-corrected cluster-level p<0.05), with age, sex and total intracranial volume as covariates.

RESULTS

GMV was inversely correlated with BI score in four clusters located in left lateral occipital cortex, bilateral angular gyri and right frontal pole. Clusters were no longer significant after controlling for diagnosis. GMV was not correlated with BI score within the MDD cohort alone.

LIMITATIONS

Incomplete clinical data required use of a modified BI scale.

CONCLUSION

BI scores were inversely correlated with GMV in unmedicated subjects with MDD and BD, but these correlations appeared driven by categorical diagnosis. Future work will examine other imaging modalities and focus on elements of the BI scale most likely to be related to brain structure and function.

Comorbidity of Attention Deficit Hyperactivity Disorder and Generalized Anxiety Disorder in children and adolescents

The aim of the study is to explore the impact of Generalized Anxiety Disorder (GAD) comorbidity in children with Attention Deficit Hyperactivity Disorder (ADHD). Six hundred children with ADHD (mean age = 9.12 years), recruited from 2013 to 2017, participated in the study. A total of 96 (16%) children with ADHD displayed a comorbidity with GAD. ADHD + GAD were compared to 504 ADHD children without GAD in terms of cognitive and psychiatric profile, ADHD subtype and family psychiatric history. The ADHD + GAD, predominantly represented from ADHD combined (72.6%), displayed higher psychiatry comorbidity, in particular with depressive disorders, and were associated with higher rates of maternal depression, of ADHD in fathers, and bipolar disorders in second degree relatives. Moreover, younger preschool-primary school age children with ADHD + GAD showed significant higher frequency of depressive disorders versus younger preschool-primary children with ADHD without GAD. ADHD + GAD comorbidity represents a more complex clinical condition compared to ADHD without GAD, characterized by the higher frequency of multiple comorbidities and by a psychiatric family with higher rates of mood and disruptive disorders.

Child and Adolescent Clinical Features Preceding Adult Suicide Attempts

The objective of this study was to identify the predictive value of juvenile factors for adult suicidal behavior. We reviewed clinical records to compare factors identified in childhood and adolescence between adult suicidal versus nonsuicidal major affective disorder subjects. Suicide attempts occurred in 23.1% of subjects. Age-at-first-symptom was 14.2 vs. 20.2 years among suicidal versus nonsuicidal subjects (p < 0.0001). More prevalent in suicidal versus non-suicidal subjects by multivariate analysis were: depressive symptoms, hyper-emotionality, younger-at-first-affective-episode, family suicide history, childhood mood-swings, and adolescence low self-esteem. Presence of one factor yielded a Bayesian sensitivity of 64%, specificity of 50%, and negative predictive power of 86%. Several juvenile factors were associated with adult suicidal behavior; their absence was strongly associated with a lack of adult suicidal behavior.

Understanding Early Age of Onset: a Review of the Last 5 Years

The age at onset of bipolar disorder ranging from childhood to adolescent to adult has significant implications for frequency, severity and duration of mood episodes, comorbid psychopathology, heritability, response to treatment, and opportunity for early intervention. There is increasing evidence that recognition of prodromal symptoms in at-risk populations and mood type at onset are important variables in understanding the course of this illness in youth. Very early childhood onset of symptoms including anxiety/depression, mood lability, and subthreshold manic symptoms, along with family history of a parent with early onset bipolar disorder, appears to predict the highest risk of early onset disorder with the most severe course.

Incidence, characteristics and course of narrow phenotype paediatric bipolar I disorder in the British Isles

OBJECTIVE

To estimate the surveillance incidence of first-time diagnosis of narrow phenotype bipolar I disorder (NPBDI) in young people under 16 years by consultants in child and adolescent psychiatry (CCAP) in the British Isles and describe symptoms, comorbidity, associated factors, management strategies and clinical outcomes at 1-year follow-up.

METHOD

Active prospective surveillance epidemiology was utilised to ask 730 CCAP to report cases of NPBDI using the child and adolescent psychiatry surveillance system.

RESULTS

Of the 151 cases of NPBDI reported, 33 (age range 10-15.11 years) met the DSM-IV analytical case definition with 60% having had previously undiagnosed mood episodes. The minimum 12-month incidence of NPBDI in the British Isles was 0.59/100 000 (95% CI 0.41-0.84). Irritability was reported in 72% cases and comorbid conditions in 51.5% cases with 48.5% cases requiring admission to hospital. Relapses occurred in 56.67% cases during the 1-year follow-up.

CONCLUSIONS

These rates suggest that the first-time diagnosis of NPBDI in young people <16 years of age by CCAP in the British Isles is infrequent; however, the rates of relapse and admission to hospital warrant close monitoring.

Childhood-compared to adolescent-onset bipolar disorder has more statistically significant clinical correlates

BACKGROUND

The strengths and limitations of considering childhood-and adolescent-onset bipolar disorder (BD) separately versus together remain to be established. We assessed this issue.

METHODS

BD patients referred to the Stanford Bipolar Disorder Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD Affective Disorders Evaluation. Patients with childhood- and adolescent-onset were compared to those with adult-onset for 7 unfavorable bipolar illness characteristics with replicated associations with early-onset patients.

RESULTS

Among 502 BD outpatients, those with childhood- (<13 years, N=110) and adolescent- (13-18 years, N=218) onset had significantly higher rates for 4/7 unfavorable illness characteristics, including lifetime comorbid anxiety disorder, at least ten lifetime mood episodes, lifetime alcohol use disorder, and prior suicide attempt, than those with adult-onset (>18 years, N=174). Childhood- but not adolescent-onset BD patients also had significantly higher rates of first-degree relative with mood disorder, lifetime substance use disorder, and rapid cycling in the prior year. Patients with pooled childhood/adolescent - compared to adult-onset had significantly higher rates for 5/7 of these unfavorable illness characteristics, while patients with childhood- compared to adolescent-onset had significantly higher rates for 4/7 of these unfavorable illness characteristics.

LIMITATIONS

Caucasian, insured, suburban, low substance abuse, American specialty clinic-referred sample limits generalizability. Onset age is based on retrospective recall.

CONCLUSIONS

Childhood- compared to adolescent-onset BD was more robustly related to unfavorable bipolar illness characteristics, so pooling these groups attenuated such relationships. Further study is warranted to determine the extent to which adolescent-onset BD represents an intermediate phenotype between childhood- and adult-onset BD.

Instruments that prospectively predict bipolar disorder - A systematic review

BACKGROUND

Identification of earlier stages of Bipolar Disorder (BD), even prior to the first manic episode, may help develop interventions to prevent or delay the onset of BD. However, reliable and valid instruments are necessary to ascertain such earlier stages of BD. The aim of the current review was to identify instruments that had predictive validity and utility for BD for use in early intervention (EI) settings for the prevention of BD.

METHODS

We undertook a systematic examination of studies that examined participants without BD I or II at baseline and prospectively explored the predictive abilities of instruments for BD onset over a period of 6 months or more. The instruments and the studies were rated with respect to their relative validity and utility predicting onset of BD for prevention or early intervention. Odds ratios and area under the curve (AUC) values were derived when not reported.

RESULTS

Six studies were included, identifying five instruments that examined sub-threshold symptoms, family history, temperament and behavioral regulation. Though none of the identified instruments had been examined in high-quality replicated studies for predicting BD, two instruments, namely the Child Behavioral Checklist - Pediatric BD phenotype (CBCL-PBD) and the General Behavioral Inventory - Revised (GBI-R), had greater levels of validity and utility.

LIMITATION

Non-inclusion of studies and instruments that incidentally identified BD on follow-up limited the breadth of the review.

CONCLUSION

Instruments that test domains such as subthreshold symptoms, behavioral regulation, family history, and temperament hold promise in predicting BD onset.

Widespread white matter tract aberrations in youth with familial risk for bipolar disorder

Few studies have examined multiple measures of white matter (WM) differences in youth with familial risk for bipolar disorder (FR-BD). To investigate WM in the FR-BD group, we used three measures of WM structure and two methods of analysis. We used fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) to analyze diffusion tensor imaging (DTI) findings in 25 youth with familial risk for bipolar disorder, defined as having both a parent with BD and mood dysregulation, and 16 sex-, age-, and IQ-matched healthy controls. We conducted a whole brain voxelwise analysis using tract based spatial statistics (TBSS). Subsequently, we conducted a complementary atlas-based, region-of-interest analysis using Diffeomap to confirm results seen in TBSS. When TBSS was used, significant widespread between-group differences were found showing increased FA, increased AD, and decreased RD in the FR-BD group in the bilateral uncinate fasciculus, cingulum, cingulate, superior fronto-occipital fasciculus (SFOF), superior longitudinal fasciculus (SLF), inferior longitudinal fasciculus, and corpus callosum. Atlas-based analysis confirmed significant between-group differences, with increased FA and decreased RD in the FR-BD group in the SLF, cingulum, and SFOF. We found significant widespread WM tract aberrations in youth with familial risk for BD using two complementary methods of DTI analysis.

Clinical characteristics of bipolar disorder: a comparative study between Argentina and the United States

BACKGROUND

Bipolar disorder presents with diverse clinical manifestations. Numerous investigators have sought to identify variables that may predict a more severe illness course.

METHODS

With the objective of studying the clinical characteristics of bipolar patients between South and North America, a comparison was performed between a sample from Argentina (n = 449) and a sample from the United States (n = 503) with respect to demographics and clinical characteristics, including presence of comorbidities.

RESULTS

The Argentinian sample had more unfavorable demographics and higher rates of prior psychiatric hospitalization and prior suicide attempt but a better social outcome. However, the sample from the United States had a higher rate of prior year rapid cycling, as well as younger bipolar disorder onset age (mean ± SD, 17.9 ± 8.4 vs. 27.1 ± 11.4 years) and more severe clinical morbidity, though there was no significant difference in terms of the total duration of the illness. Argentinian compared to American patients were taking more mood stabilizers and benzodiazepines/hypnotics, but fewer antipsychotics and other psychotropic medications, when considering patients in aggregate as well as when stratifying by illness subtype (bipolar I versus bipolar II) and by illness onset age (≤21 vs. >21 years). However, there was no significant difference in rate of antidepressant prescription between the two samples considered in aggregate.

CONCLUSIONS

Although possessing similar illness durations, these samples presented significant clinical differences and distinctive prescription patterns. Thus, though the Argentinian compared to North American patients had more unfavorable demographics, they presented a better social outcome and, in several substantive ways, more favorable illness characteristics. In both samples, early onset (age ≤ 21 years) was a marker for poor prognosis throughout the illness course, although this phenomenon appeared more robust in North America.

Excessive mood elevation and behavioral activation with antidepressant treatment of juvenile depressive and anxiety disorders: a systematic review

BACKGROUND

The prevalence, characteristics and implications of excessive arousal-activation in children and adolescents treated with antidepressants for specific illnesses have not been systematically examined.

METHODS

We compared reports of antidepressant trials (n = 6,767 subjects) in juvenile depressive (n = 17) and anxiety disorders (n = 25) for consensus-based indications of psychopathological mood elevation or behavioral activation.

RESULTS

Rates of excessive arousal-activation during treatment with antidepressants were at least as high in juvenile anxiety (13.8%) as depressive (9.79%) disorders, and much lower with placebos (5.22 vs. 1.10%, respectively; both p < 0.0001). The antidepressant/placebo risk ratio for such reactions in paired comparisons was 3.50 (12.9/3.69%), and the meta-analytically pooled rate ratio was 1.7 (95% confidence interval: 1.2-2.2; both p ≤ 0.001). Overall rates for 'mania or hypomania', specifically, were 8.19% with and 0.17% without antidepressant treatment, with large drug/placebo risk ratios among depressive (10.4/0.45%) and anxiety (1.98/0.00%) disorder patients.

CONCLUSIONS

Risks of excessive mood elevation during antidepressant treatment, including mania-hypomania, were much greater than with placebo, and similar in juvenile anxiety and depressive disorders. Excessive arousal-activation in children or adolescents treated with antidepressants for anxiety as well as depressive disorders calls for particular caution and monitoring for potential risk of future bipolar disorder.

Differentiating bipolar disorder-not otherwise specified and severe mood dysregulation

OBJECTIVE

Bipolar disorder-not otherwise specified (BP-NOS) and severe mood dysregulation (SMD) are severe mood disorders that were defined to address questions about the diagnosis of bipolar disorder (BD) in youth. SMD and BP-NOS are distinct phenotypes that differ in clinical presentation and longitudinal course. The purpose of this review is to inform clinicians about the clinical features of the two phenotypes and about the research literature distinguishing them.

METHOD

A literature review was performed on SMD as studied in the National Institute of Mental Health Intramural Research Program and on BP-NOS in youth. For BP-NOS, the phenotype defined in the Course of Bipolar Youth study is the focus, because this has received the most study.

RESULTS

SMD is characterized by impairing, chronic irritability without distinct manic episodes. Most commonly, BP-NOS is characterized by manic, mixed, or hypomanic episodes that are too short to meet the DSM-IV-TR duration criterion. Research provides strong, albeit suggestive, evidence that SMD is not a form of BD; the most convincing evidence are longitudinal data indicating that youth with SMD are not at high risk to develop BD as they age. The BP-NOS phenotype appears to be on a diagnostic continuum with BD types I and II. Subjects with BP-NOS and those with BD type I have similar symptom and family history profiles, and youth with BP-NOS are at high risk to develop BD as they age. Currently, little research guides treatment for either phenotype.

CONCLUSIONS

Pressing research needs include identifying effective treatments for these phenotypes, ascertaining biomarkers that predict conversion from BP-NOS to BD, elucidating associations between SMD and other disorders, and defining the neural circuitry mediating each condition.

Juvenile bipolar disorder and suicidality: a review of the last 10 years of literature

Although children and adolescents with bipolar disorder (BD) are at elevated risk for suicide, little research to date has been conducted on suicidality in this population. The purpose of this descriptive review of the past 10 years of scientific literature on suicidality in youths with BD was to identify the risk and protective factors associated with this phenomenon, and to discuss the implications for research and clinical practice. Searches on Medline and PsycINFO databases for the period from early 2002 to mid-2012 yielded 16 relevant articles, which were subsequently explored using an analysis grid. Note that the authors employed a consensus analysis approach at all stages of the review. Four primary categories of risk factors for suicidality in youths with BD were identified: demographic (age and gender), clinical (depression, mixed state or mixed features specifier, mania, anxiety disorders, psychotic symptoms, and substance abuse), psychological (cyclothymic temperament, hopelessness, poor anger management, low self-esteem, external locus of control, impulsivity and aggressiveness, previous suicide attempts, and history of suicide ideation, non-suicidal self-injurious behaviors and past psychiatric hospitalization), and family/social (family history of attempted suicide, family history of depression, low quality of life, poor family functioning, stressful life events, physical/sexual abuse, and social withdrawal). Youths with BD who experienced more complex symptomatic profiles were at greater risk of suicidality. Few protective factors associated with suicidality have been studied among youths with BD. One protective factor was found in this descriptive literature review: the positive effects of dialectical behavior therapy. This article allows a better appreciation of the risk and protective factors associated with suicidality among youth with BD. Greater awareness of risk factors is the first step in suicide prevention.

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.

Further evidence that pediatric-onset bipolar disorder comorbid with ADHD represents a distinct subtype: results from a large controlled family study

We used familial risk analysis to clarify the diagnostic comorbidity between pediatric BP-I disorder and ADHD, testing the hypothesis that pediatric-BP-I disorder comorbid with ADHD represents a distinct subtype. Structured diagnostic interviews were used to obtain DSM-IV psychiatric diagnoses on first-degree relatives (n = 726) of referred children and adolescents satisfying diagnostic criteria for BP-I disorder (n = 239). For comparison, diagnostic information on the first-degree relatives (N = 511) of non-bipolar ADHD children (N = 162) and the first degree relatives (N = 411) of control children (N = 136) with neither ADHD nor BP-I disorder were examined. BP-I disorder and ADHD in probands bred true irrespective of the comorbidity with the other disorder. We also found that the comorbid condition of BP-I disorder plus ADHD also bred true in families, and the two disorders co-segregated among relatives. This large familial risk analysis provides compelling evidence that pediatric BP-I disorder comorbid with ADHD represents a distinct familial subtype.

Risks for the transition from major depressive disorder to bipolar disorder in the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

It is currently not possible to determine which individuals with unipolar depression are at highest risk for a manic episode. This study investigates clinical and psychosocial risk factors for mania among individuals with major depressive disorder (MDD), indicating diagnostic conversion from MDD to bipolar I disorder.

METHOD

We fitted logistic regression models to predict the first onset of a manic episode among 6,214 cases of lifetime MDD according to DSM-IV criteria in the National Epidemiologic Survey on Alcohol and Related Conditions. Participants in this survey were interviewed twice over a period of 3 years, in 2000-2001 and in 2004-2005, and survey data were gathered using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV.

RESULTS

Approximately 1 in 25 individuals with MDD transitioned to bipolar disorder during the study's 3-year follow-up period. Demographic risk factors for the transition from MDD to bipolar disorder included younger age, black race/ethnicity, and less than high school education. Clinical characteristics of depression (eg, age at first onset, presence of atypical features) were not associated with diagnostic conversion. However, prior psychopathology was associated with the transition to bipolar disorder: history of social phobia (odds ratio [OR] = 2.20; 95% confidence interval [CI], 1.47-3.30) and generalized anxiety disorder (OR = 1.58; 95% CI, 1.06-2.35). Lastly, we identified environmental stressors over the life course that predicted the transition to bipolar disorder: these include a history of child abuse (OR = 1.26; 95% CI, 1.12-1.42) and past-year problems with one's social support group (OR = 1.79; 95% CI, 1.19-2.68). The overall predictive power of these risk factors based on a receiver operating curve analysis is modest.

CONCLUSIONS

A wide range of demographic, clinical, and environmental risk factors were identified that indicate a heightened risk for the transition to bipolar disorder. Additional work is needed to further enhance the prediction of bipolar disorder among cases of MDD and to determine whether interventions targeting these factors could reduce the risk of bipolar disorder.

Prevalence, clinical presentation and differential diagnosis of pediatric bipolar disorder

BACKGROUND

Over the past 20 years, the evidence regarding pediatric bipolar disorder (BP) has increased substantially. As a result, recent concerns have focused primarily on prevalence and differential diagnosis.

METHOD

Selective review of the literature.

RESULTS

BP as defined by rigorously applying diagnostic criteria has been observed among children and especially adolescents in numerous countries. In contrast to increasing diagnoses in clinical settings, prevalence in epidemiologic studies has not recently changed. BPspectrum conditions among youth are highly impairing and confer high risk for conversion to BP-I and BP-II. Compared to adults, youth with BP have more mixed symptoms, more changes in mood polarity, are more often symptomatic and seem to have worse prognosis. The course, clinical characteristics, and comorbidities of BP among children and adolescents are in many ways otherwise similar to those of adults with BP. Nonetheless, many youth with BP receive no treatment and most do not receive BP-specific treatment.

CONCLUSION

Despite increased evidence supporting the validity of pediatric BP, discrepancies between clinical and epidemiologic findings suggest that diagnostic misapplication may be common. Simultaneously, low rates of treatment of youth with BP suggest that withholding of BP diagnoses may also be common. Clinicians should apply diagnostic criteria rigorously in order to optimize diagnostic accuracy and ensure appropriate treatment.

Tools to improve differential diagnosis of bipolar disorder in primary care

Among patients seen in a primary care setting for depressive and/or anxiety symptoms, 20% to 30% are estimated to have bipolar disorder. Although relatively common in primary care settings, bipolar disorder is still underrecognized, primarily due to misdiagnosis as unipolar depression. Patients often seek treatment when they are depressed but uncommonly present with mania or hypomania, the specific markers of bipolar spectrum disorders. An awareness of the prevalence, characteristics, and predictors of bipolar disorder can help the primary care physician to properly differentiate between bipolar depression and unipolar depression. Completing a differential diagnosis of bipolar disorder requires obtaining a comprehensive patient history that investigates symptom phenomenology and associated features, family history, longitudinal course of illness, and prior treatment response. In addition to the clinical interview, the Mood Disorder Questionnaire and the World Health Organization Composite International Diagnostic Interview 3.0 can be useful tools for evaluating patients for bipolar disorder. Screening patients at risk for bipolar disorder will help to avoid the use of unproductive or possibly even harmful treatments.

Psychosocial functioning, familiality, and psychiatric comorbidity in bipolar youth with and without psychotic features

OBJECTIVE

Few studies have examined the correlates of psychosis in children and adolescents with bipolar disorder (BPD). We examined psychiatric comorbidity, familiality, and psychosocial functioning in multiple domains in BPD children and adolescents with and without psychotic features.

METHOD

As part of 2 ongoing family-based studies of children and adolescents with DSM-IV-defined BPD, we compared youth and their families with psychotic symptoms (BPD+P) and without psychotic symptoms (BPD-P). All youth and family members were assessed using indirect and direct structured psychiatric interviews (Kiddie Schedule for Affective Disorders-Epidemiologic Version and DSM-IV Structured Clinical Interview) in a blinded manner. One study was conducted from January 2000 through December 2004, and the other study was conducted from February 1997 through September 2006.

RESULTS

Of the 226 youth with BPD, 33% manifested psychotic symptoms, as defined by the presence of hallucinations or delusions. We found that BPD+P youth had a greater number of BPD episodes (P < .01), more psychiatric hospitalizations (P < .01), and significantly higher rates of psychiatric comorbidity compared to BPD-P youth (all P values < .05). Additionally, a higher percentage of BPD+P youth had a family history of psychosis (P = .01). There was a lower processing speed (P = .03) and lower arithmetic scaled score (P = .04) in BPD+P youth, but no other meaningful differences in cognitive variables were identified between the 2 BPD groups. Psychosis in BPD was also associated with decreased family cohesion (P = .04) and poorer overall global functioning (P < .01).

CONCLUSIONS

In children and adolescents with BPD, those who manifest psychotic features have higher rates of comorbid psychopathology, family history of psychosis, and poorer overall functioning in multiple domains than BPD children without psychosis. Future studies should examine neuroimaging correlates, medication response, and longitudinal course of children and adolescents with BPD who manifest psychosis as part of their clinical picture.

Lifetime psychopathology among the offspring of Bipolar I parents

BACKGROUND

Recent studies have demonstrated high rates of psychopathology in the offspring of parents with bipolar disorder. The aim of this study was to identify psychiatric diagnoses in a sample of children of bipolar parents.

METHOD

This case series comprised 35 children and adolescents aged 6 to 17 years, with a mean age of 12.5 ± 2.9 years (20 males and 15 females), who had at least one parent with bipolar disorder type I. The subjects were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version (K-SADS-PL). Family psychiatric history and demographics were also evaluated.

RESULTS

Of the offspring studied, 71.4% had a lifetime diagnosis of at least one psychiatric disorder (28.6% with a mood disorder, 40% with a disruptive behavior disorder and 20% with an anxiety disorder). Pure mood disorders (11.4%) occurred less frequently than mood disorders comorbid with attention deficit hyperactivity disorder (17.1%). Psychopathology was commonly reported in second-degree relatives of the offspring of parents with bipolar disorder (71.4%).

CONCLUSIONS

Our results support previous findings of an increased risk for developing psychopathology, predominantly mood and disruptive disorders, in the offspring of bipolar individuals. Prospective studies with larger samples are needed to confirm and expand these results.

Clinical course of children with a depressive spectrum disorder and transient manic symptoms

OBJECTIVE

To assess rates of conversion to bipolar spectrum disorder (BPSD) and risk factors associated with conversion in children with depressive spectrum disorders (DSD) and transient manic symptoms (TMS) over 18 months. TMS are manic-like symptoms of insufficient duration or number to warrant a diagnosis of BPSD.

METHODS

Participants were 165 children (mean = 9.9 years, SD = 1.3) with mood disorders from the Multi-Family Psychoeducational Psychotherapy (MF-PEP) treatment study: 37 with DSD+TMS, 13 with DSD, and 115 with BPSD. All were assessed with standardized instruments on four occasions over 18 months, with half receiving MF-PEP after their baseline assessment and half receiving MF-PEP after a one-year wait-list condition.

RESULTS

At baseline, the Children's Global Assessment Scale scores did not differ significantly between the DSD+TMS, DSD, and BPSD groups. Conversion rates to BPSD were significantly higher for the DSD+TMS group (48.0%) compared to the DSD group (12.5%). Conversion was significantly more frequent for participants in the one-year wait-list control group (60%) compared to the immediate treatment group (16%). Clinical presentation, family environment, and family history did not differ significantly between the small subset of DSD+TMS participants who did convert to BPSD at follow-up and those who did not convert. Baseline functional impairment was greater for the converted group than the non-converted group.

CONCLUSIONS

Transient manic symptoms are a risk factor for eventual conversion to BPSD; psychoeducational psychotherapy may be protective. As this exploratory study had a small sample size and did not correct for multiple comparisons, additional studies with larger sample sizes are needed.

A controlled family study of children with DSM-IV bipolar-I disorder and psychiatric co-morbidity

BACKGROUND

To estimate the spectrum of familial risk for psychopathology in first-degree relatives of children with unabridged DSM-IV bipolar-I disorder (BP-I).

METHOD

We conducted a blinded, controlled family study using structured diagnostic interviews of 157 children with BP-I probands (n=487 first-degree relatives), 162 attention deficit hyperactivity disorder (ADHD) (without BP-I) probands (n=511 first-degree relatives), and 136 healthy control (without ADHD or BP-I) probands (n=411 first-degree relatives).

RESULTS

The morbid risk (MR) of BP-I disorder in relatives of BP-I probands (MR=0.18) was increased 4-fold [95% confidence interval (CI) 2.3-6.9, p<0.001] over the risk to relatives of control probands (MR=0.05) and 3.5-fold (95% CI 2.1-5.8, p<0.001) over the risk to relatives of ADHD probands (MR=0.06). In addition, relatives of children with BP-I disorder had high rates of psychosis, major depression, multiple anxiety disorders, substance use disorders, ADHD and antisocial disorders compared with relatives of control probands. Only the effect for antisocial disorders lost significance after accounted for by the corresponding diagnosis in the proband. Familial rates of ADHD did not differ between ADHD and BP-I probands.

CONCLUSIONS

Our results document an increased familial risk for BP-I disorder in relatives of pediatric probands with DSM-IV BP-I. Relatives of probands with BP-I were also at increased risk for other psychiatric disorders frequently associated with pediatric BP-I. These results support the validity of the diagnosis of BP-I in children as defined by DSM-IV. More work is needed to better understand the nature of the association between these disorders in probands and relatives.

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

OBJECTIVE

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

REVIEW PROCESS

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

OUTCOMES

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

CONCLUSIONS

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

Staging perspectives in neurodevelopmental aspects of neuropsychiatry: agents, phases and ages at expression

Neurodevelopmental risk factors have assumed a critical role in prevailing notions concerning the etiopathogenesis of neuropsychiatric disorders. Staging, diagnostic elements at which phase of disease is determined, provides a means of conceptualizing the degree and extent of factors affecting brain development trajectories, but is concurrently specified through the particular interactions of genes and environment unique to each individual case. For present purposes, staging perspectives in neurodevelopmental aspects of the disease processes are considered from conditions giving rise to neurodevelopmental staging in affective states, adolescence, dopamine disease states, and autism spectrum disorders. Three major aspects influencing the eventual course of individual developmental trajectories appear to possess an essential determinant influence upon outcome: (i) the type of agent that interferes with brain development, whether chemical, immune system activating or absent (anoxia/hypoxia), (ii) the phase of brain development at which the agent exerts disruption, whether prenatal, postnatal, or adolescent, and (iii) the age of expression of structural and functional abnormalities. Clinical staging may be assumed at any or each developmental phase. The present perspective offers both a challenge to bring further order to diagnosis, intervention, and prognosis and a statement regarding the extreme complexities and interwoven intricacies of epigenetic factors, biomarkers, and neurobehavioral entities that aggravate currents notions of the neuropsychiatric disorders.

Family psychiatric history, peritraumatic reactivity, and posttraumatic stress symptoms: a prospective study of police

BACKGROUND

Family history of psychiatric and substance use disorders has been associated with posttraumatic stress disorder (PTSD) in cross-sectional studies.

METHOD

Using a prospective design, we examined the relationships of family history of psychiatric and substance use disorders to posttraumatic stress symptoms in 278 healthy police recruits. During academy training, recruits were interviewed on family and personal psychopathology, prior cumulative civilian trauma exposure, and completed self-report questionnaires on nonspecific symptoms of distress and alcohol use. Twelve months after commencement of active duty, participants completed questionnaires on critical incident exposure over the previous year, peritraumatic distress to the worst critical incident during this time, and posttraumatic stress symptoms.

RESULTS

A path model indicated: (1) family loading for mood and anxiety disorders had an indirect effect on posttraumatic stress symptoms at 12 months that was mediated through peritraumatic distress to the officer's self-identified worst critical incident, (2) family loading for substance use disorders also predicted posttraumatic stress symptoms at 12 months and this relationship was mediated through peritraumatic distress.

CONCLUSION

These findings support a model in which family histories of psychopathology and substance abuse are pre-existing vulnerability factors for experiencing greater peritraumatic distress to critical incident exposure which, in turn, increases the risk for development of symptoms of posttraumatic stress disorder. Replication in other first responders, military and civilians will be important to determine generalizability of these findings.

Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study

OBJECTIVE

The authors sought to assess the longitudinal course of youths with bipolar spectrum disorders over a 4-year period.

METHOD

At total of 413 youths (ages 7-17 years) with bipolar I disorder (N=244), bipolar II disorder (N=28), and bipolar disorder not otherwise specified (N=141) were enrolled in the study. Symptoms were ascertained retrospectively on average every 9.4 months for 4 years using the Longitudinal Interval Follow-Up Evaluation. Rates and time to recovery and recurrence and week-by-week symptomatic status were analyzed.

RESULTS

Approximately 2.5 years after onset of their index episode, 81.5% of the participants had fully recovered, but 1.5 years later 62.5% had a syndromal recurrence, particularly depression. One-third of the participants had one syndromal recurrence, and 30% had two or more. The polarity of the index episode predicted that of subsequent episodes. Participants were symptomatic during 60% of the follow-up period, particularly with subsyndromal symptoms of depression and mixed polarity, with numerous changes in mood polarity. Manic symptomatology, especially syndromal, was less frequent, and bipolar II was mainly manifested by depressive symptoms. Overall, 40% of the participants had syndromal or subsyndromal symptoms during 75% of the follow-up period, and 16% of the participants experienced psychotic symptoms during 17% the follow-up period. Twenty-five percent of youths with bipolar II converted to bipolar I, and 38% of those with bipolar disorder not otherwise specified converted to bipolar I or II. Early onset, diagnosis of bipolar disorder not otherwise specified, long illness duration, low socioeconomic status, and family history of mood disorders were associated with poorer outcomes.

CONCLUSIONS

Bipolar spectrum disorders in youths are characterized by episodic illness with subsyndromal and, less frequently, syndromal episodes with mainly depressive and mixed symptoms and rapid mood changes.

Irritability without elation in a large bipolar youth sample: frequency and clinical description

OBJECTIVE

To determine whether some children with bipolar disorder (BP) manifest irritability without elation and whether these children differ on sociodemographic, phenotypic, and familial features from those who have elation and no irritability and from those who have both.

METHOD

Three hundred sixty-one youths with BP recruited into the three-site Course and Outcome of Bipolar Illness in Youth study were assessed at baseline and for most severe past symptoms using standardized semistructured interviews. Bipolar disorder subtype was identified, and frequency and severity of manic symptoms were quantified. The subjects were required to have episodic mood disturbance to be diagnosed with BP. The sample was then reclassified and compared based on the most severe lifetime manic episode into three subgroups: elated only, irritable only, and both elated and irritable.

RESULTS

Irritable-only and elated-only subgroups constituted 10% and 15% of the sample, respectively. Except for the irritable-only subjects being significantly younger than the other two subgroups, there were no other between-group sociodemographic differences. There were no significant between-group differences in the BP subtype, rate of psychiatric comorbidities, severity of illness, duration of illness, and family history of mania in first- or second-degree relatives and other psychiatric disorders in first-degree relatives, with the exception of depression and alcohol abuse occurring more frequently in the irritability-only subgroup. The elated-only group had higher scores on most DSM-IV mania criterion B items.

CONCLUSIONS

The results of this study support the DSM-IV A criteria for mania in youths. Irritable-only mania exists, particularly in younger children, but similar to elated-only mania, it occurs infrequently. The fact that the irritable-only subgroup has similar clinical characteristics and family histories of BP, as compared with subgroups with predominant elation, provides support for continuing to consider episodic irritability in the diagnosis of pediatric BP.

Practitioner review: the assessment of bipolar disorder in children and adolescents

BACKGROUND

An increasing number of youth are being diagnosed with, and treated for, bipolar disorder (BD). Controversy exists about whether youth with non-episodic irritability and symptoms of attention deficit hyperactivity disorder (ADHD) should be considered to have a developmental presentation of mania.

METHOD

A selective review of the literature related to this question, along with recommendations to guide clinical assessment.

RESULTS

Data indicate differences between youth with episodic mania and those with non-episodic irritability in longitudinal diagnostic associations, family history, and pathophysiology. In youth with episodic mania, elation and irritability are both common during manic episodes.

CONCLUSIONS

In diagnosing mania in youth, clinicians should focus on the presence of episodes that consist of a distinct change in mood accompanied by concurrent changes in cognition and behavior. BD should not be diagnosed in the absence of such episodes. In youth with ADHD, symptoms such as distractibility and agitation should be counted as manic symptoms only if they are markedly increased over the youth's baseline symptoms at the same time that there is a distinct change in mood and the occurrence of other associated symptoms of mania. Although different techniques for diagnosing comorbid illnesses have not been compared systematically, it appears most rational to diagnose co-occurring illnesses such as ADHD only if the symptoms of the co-occurring illness are present when the youth is euthymic.

AACAP 2006 Research Forum--Advancing research in early-onset bipolar disorder: barriers and suggestions

OBJECTIVE

The 2006 Research Forum addressed the goal of formulating a research agenda for early-onset bipolar disorder (EOBP) and improving outcome by understanding the risk and protective factors that contribute to its severity and chronicity.

METHOD

Five work groups outlined barriers and research gaps in EOBP genetics, neuroimaging, prodromes, psychosocial factors, and pharmacotherapy.

RESULTS

There was agreement that the lack of consensus on the definition and diagnosis of EOBP is the primary barrier to advancing research in BP in children and adolescents. Related issues included: the difficulties in managing co-morbidity both statistically and clinically; acquiring adequate sample sizes to study the genetics, biology, and treatment; understanding the EOBP's developmental aspects; and identifying environmental mediators and moderators of risk and protection. Similarly, both psychosocial and medication treatment strategies for children with BP are hamstrung by diagnostic issues. To advance the research in EOBP, both training and funding mechanisms need to be developed with these issues in mind.

CONCLUSIONS

EOBP constitutes a significant public health concern. Barriers are significant but identifiable and thus are not insurmountable. To advance the understanding of EOBP, the field must be committed to resolving diagnostic and assessment issues. Once achieved, with adequate personnel and funding resources, research into the field of EOBP will doubtless be advanced at a rapid pace.

Comparison of manic and depressive symptoms between children and adolescents with bipolar spectrum disorders

OBJECTIVE

To compare the most severe lifetime (current or past) mood symptoms, duration of illness, and rates of lifetime comorbid disorders among youth with bipolar spectrum disorders [BP (bipolar-I, bipolar-II and bipolar-not otherwise specified)].

METHODS

A total of 173 children (<12 years) with BP, 101 adolescents with childhood-onset BP, and 90 adolescents with adolescent-onset BP were evaluated with standardized instruments.

RESULTS

Depression was the most common initial and frequent episode for both adolescent groups, followed by mania/hypomania. Adolescents with childhood-onset BP had the longest illness, followed by children and then adolescents with adolescent-onset BP. Adjusting for sex, socioeconomic status, and duration of illness, while manic, both adolescent groups showed more 'typical' and severe manic symptoms. Mood lability was more frequent in childhood-onset and adolescents with early-onset BP. While depressed, both adolescent groups showed more severe depressive symptoms, higher rates of melancholic and atypical symptoms, and suicide attempts than children. Depressed children had more severe irritability than depressed adolescents. Early BP onset was associated with attention-deficit hyperactivity disorder, whereas later BP onset was associated with panic, conduct, and substance use disorders. Above-noted results were similar when each BP subtype was analyzed separately.

CONCLUSIONS

Older age was associated with more severe and typical mood symptomatology. However, there were differences and similarities in type, intensity, and frequency of BP symptoms and comorbid disorders related to age of onset and duration of BP and level of psychosocial development. These factors and the normal difficulties youth have expressing and modulating their emotions may explain existing complexities in diagnosing and treating BP in youth, particular in young children, and suggest the need for developmentally sensitive treatments.

Does conduct disorder mediate the development of substance use disorders in adolescents with bipolar disorder? A case-control family study

BACKGROUND

Recent work has highlighted important relationships among conduct disorder (CD), substance use disorders (SUD), and bipolar disorder in youth. However, because bipolar disorder and CD are frequently comorbid in the young, the impact of CD in mediating SUD in bipolar disorder youth remains unclear.

METHOD

105 adolescents with DSM-IV bipolar disorder (mean +/- SD age = 13.6 +/- 2.50 years) and 98 controls (mean +/- SD age = 13.7 +/- 2.10 years) were comprehensively assessed with a structured psychiatric diagnostic interview for psychopathology and SUD. The study was conducted from January 2000 through December 2004.

RESULTS

Among bipolar disorder youth, those with CD were more likely to report cigarette smoking and/or SUD than youth without CD. However, CD preceding SUD or cigarette smoking did not significantly increase the subsequent risk of SUD or cigarette smoking. Adolescents with bipolar disorder and CD were significantly more likely to manifest a combined alcohol plus drug use disorder compared to subjects with bipolar disorder without CD (chi(2) = 11.99, p < .001).

CONCLUSIONS

While bipolar disorder is a risk factor for SUD and cigarette smoking in a sample of adolescents, comorbidity with preexisting CD does not increase the risk for SUD. Further follow-up of this sample through the full risk of SUD into adulthood is necessary to confirm these findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Pharmacotherapy in bipolar disorders during childhood and adolescence]

OBJECTIVE

Bipolar disorders during childhood and adolescence are rare, but serious and highly recurrent disorders, often associated with negative outcome. Pharmacotherapy, including Lithium, other mood stabilizers and typical antipsychotic agents, is the first-line treatment in bipolar disorders and often necessary for many months or years.

METHOD

A computerized medline-search (Pubmed) was made for prospective studies and reviews of bipolar disorder in this age-group published during the last 10 years, which were then reviewed for their relevance.

RESULTS

Despite the widespread use of substances whose efficacy for adults is well-established, there is a substantial lack of empirical data regarding the efficacy and safety in the treatment of bipolar disorder in children and adolescents. Placebo-controlled studies are very rare, and the interpretation of the existing data is complicated by the diagnostic controversy about bipolar disorder in children. Side-effects are more common in children and adolescents than in adults.

CONCLUSIONS

Combination therapy may be favoured in cases of severe and psychotic bipolar disorder. Needed are more placebo-controlled studies and long-term studies on the efficacy and safety of mood stabilizers and atypical antipsychotic agents in the treatment of 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.

Current research in child and adolescent bipolar disorder

Although recently more research has considered children with bipolar disorder than in the past, much controversy still surrounds the validity of the diagnosis. Furthermore, questions remain as to whether or not childhood expressions of bipolarity are continuous with adult manifestations of the illness. In order to advance current knowledge of bipolar disorders in children, researchers have begun to conduct phenomenological, longitudinal, treatment, and neuroimaging studies in youths who exhibit symptoms of bipolar illness, as well as offspring of parents with bipolar disorders. Regardless of the differences between research groups regarding how bipolar disorder in children is defined, it is agreed that pediatric bipolarity is a serious and pernicious illness. With early intervention during the period of time in which youths are exhibiting subsyndromal symptoms of pediatric bipolarity, it appears that the progression of the illness to the more malignant manifestation of the disorder may be avoided. This paper will review what is currently known and what still is left to learn about clinically salient topics that pertain to bipolar disorder in children and adolescents.

Pediatric bipolar disorder: recognition in primary care

PURPOSE OF REVIEW

Bipolar disorder (BPD) is increasingly diagnosed in youth in both outpatient and inpatient settings. Research on BPD in youth has also increased dramatically; this paper summarizes issues of clinical relevance in primary care, advancements in the last year, and areas in which more research is needed.

RECENT FINDINGS

Key issues and new developments are summarized in the following areas such as epidemiology and relevance, assessment and differential diagnosis, patient and family decision support, shared decision making and triage, treatment, and monitoring and collaboration with mental health professionals. Recent practice guidelines have important implications for diagnosis and treatment.

SUMMARY

Early-onset BPD appears to have a more severe course and more comorbidity than later life onset, as well as longer delays in treatment seeking. Affected children show differences in cognitive functioning and neuroanatomy compared with the general population. Assessment of BPD in children needs to be comprehensive and longitudinal, as diagnosis remains a debated topic. Medications are a primary part of treatment, but more double-blind, placebo-controlled trials are needed. Psychosocial adjunctive treatment is important. Children with a family history of BPD are at risk for impaired functioning and psychopathology; high-risk studies will increase our understanding of the onset and course of BPD.

Parent-child interactions in pediatric bipolar disorder

Parent-child relationships may have a significant effect on illness characteristics of children with pediatric bipolar disorder (PBD), and these relationships may, in turn, be affected by the child's illness. We characterized maternal reports of parent-child relationships using the five-factor Parent-Child Relationship Questionnaire (PCRQ) in 60 families (30 PBD youth and 30 matched controls). Data on child proband and parental psychopathology were also obtained. Compared to controls, parent-child relationships in the PBD group were characterized by significantly less warmth, affection, and intimacy, and more quarreling and forceful punishment. Among PBD participants, elevated symptoms of mania, comorbid ADHD, an earlier age of illness onset, living in a single parent home, and the presence of a parental mood disorder were associated with greater parent-child relationship difficulties. These findings have implications for the development of interventions that focus on the quality of parent-child relationships, in addition to symptom management, in the treatment of PBD.

[The genetics of depressive disorders]

Among the most common severe psychiatric disorders worldwide, depressive disorders are a leading cause of morbidity, the onset usually occurring during childhood or adolescence. Symptomatology, prevalence, outcome and treatment differentiate depressive disorder nosologically as being either unipolar depression or bipolar disorder, which is characterized by one or more episodes of mania with or without episodes of depression. Genetic factors decisively influence the susceptibility to depressive disorders. Family studies and twin studies have been essential in defining the magnitude of familial risk and liability to heritability, particularly in the case of bipolar disorder. In recent years, linkage and association studies have made great strides towards identifying candidate genes. Particularly the s-allele of the serotonin transporter has been repeatedly confirmed to be a risk factor. Meta-analyses suggest, however, that the genetic contributions of the ascertained loci are relatively small. Along with genetic factors, environmental factors are heavily involved. Gene-environment action plays a pivotal role, particularly in unipolar depression. The genetic disposition seems to be modulated by a protective or pathogenic environment. Early-onset disorders must be further investigated in future as studies to date are somewhat limited.

Three-dimensional mapping of hippocampal anatomy in adolescents with bipolar disorder

OBJECTIVE

Early-onset bipolar disorder is thought to be a particularly severe variant of the illness. Continuity with the adult form of illness remains unresolved, but preliminary evidence suggests similar biological underpinnings. Recently, we observed localized hippocampal decreases in unmedicated adults with bipolar disorder that were not detectable with conventional volumetric measures. Using the same three-dimensional mapping methods, we sought to investigate whether a similar pattern exists in adolescents with bipolar disorder.

METHOD

High-resolution brain magnetic resonance images were acquired from 16 adolescents meeting DSM-IV criteria for bipolar disorder (mean age 15.5 +/- 3.4 years, 50% female) and 20 demographically matched, typically developing control subjects. Three-dimensional parametric mesh models of the hippocampus were created from manual tracings of the hippocampal formation.

RESULTS

Controlling for total brain volume, total hippocampal volume was significantly smaller in adolescent patients with bipolar disorder relative to controls (by 9.2%). Statistical mapping results, confirmed by permutation testing, revealed significant localized deformations in the head and tail of the left hippocampus in adolescents with bipolar disorder, relative to normal controls. In addition, there was a significant positive correlation between hippocampal size and age in patients with bipolar disorder, whereas healthy controls showed an inverse relation.

DISCUSSION

Localized hippocampal deficits in adolescent patients with bipolar disorder suggest a possible neural correlate for memory deficits observed in this illness. Moreover, age-related increases in hippocampal size in patients with bipolar disorder, not observed in healthy controls, may reflect abnormal developmental mechanisms in bipolar disorder. This possibility must be confirmed by longitudinal studies.

Biologic basis of bipolar disorder in children and adolescents

Bipolar disorder is a serious and difficult-to-treat condition in any age group. In childhood and adolescence, diagnosis and treatment present specific challenges, as the disorder often manifests in atypical presentations, such as marked irritability and frequent alterations of mood states not typically seen in adults. The lack of double-blind, placebo-controlled studies in pediatric populations also leads to many difficult pharmacologic challenges. In this paper, we review available studies in neuroanatomy, neurochemistry, neurocognitive functioning, and genetics to further explore the underlying neurobiologic mechanisms of child and adolescent bipolar disorder. Future investigation should elicit distinct mechanisms for diagnosing and treating bipolar disorder from a neurobiologic perspective.

Frontiers between attention deficit hyperactivity disorder and bipolar disorder

The co-occurrence of attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received much recent attention in the literature. The authors review the literature examining associations between ADHD and bipolar disorder in children, and data concerning severe irritability in youth with ADHD. This article focuses on (1) population-based studies examining ADHD and bipolar disorder or ADHD and co-occurring irritability, (2) the co-occurrence and prospective relationships of ADHD and bipolar disorder in clinical samples, (3) phenomenology and assessment of bipolar disorder and ADHD, (4) treatment of comorbid ADHD and bipolar disorder, (5) family and genetic studies of ADHD and bipolar disorder, and (6) pathophysiologic comparisons between children with ADHD and irritability and bipolar disorder. We draw on the research to make clinical recommendations and highlight important directions for future research.