Pediatric bipolar spectrum disorder and ADHD: comparison and comorbidity in the LAMS clinical sample

Association between relative age at school and persistence of ADHD in prospective studies: an individual participant data meta-analysis

BACKGROUND

The youngest children in a school class are more likely than the oldest to be diagnosed with ADHD, but this relative age effect is less frequent in older than in younger school-grade children. However, no study has explored the association between relative age and the persistence of ADHD diagnosis at older ages. We aimed to quantify the association between relative age and persistence of ADHD at older ages.

METHODS

For this meta-analysis, we searched MEDLINE, Embase, CINAHL, PsycINFO, and PubPsych up to April 1, 2022, with terms related to "cohort" and "ADHD" with no date, publication type, or language restrictions. We gathered individual participant data from prospective cohorts that included at least ten children identified with ADHD before age 10 years. ADHD was defined by either a clinical diagnosis or symptoms exceeding clinical cutoffs. Relative age was recorded as the month of birth in relation to the school-entry cutoff date. Study authors were invited to share raw data or to apply a script to analyse data locally and generate anonymised results. Our outcome was ADHD status at a diagnostic reassessment, conducted at least 4 years after the initial assessment and after age 10 years. No information on sex, gender, or ethnicity was collected. We did a two-stage random-effects individual participant data meta-analysis to assess the association of relative age with persistence of ADHD at follow-up. This study was registered with PROSPERO, CRD42020212650.

FINDINGS

Of 33 119 studies generated by our search, we identified 130 eligible unique studies and were able to gather individual participant data from 57 prospective studies following up 6504 children with ADHD. After exclusion of 16 studies in regions with a flexible school entry system that did not allow confident linkage of birthdate to relative age, the primary analysis included 41 studies in 15 countries following up 4708 children for a period of 4 to 33 years. We found that younger relative age was not statistically significantly associated with ADHD persistence at follow-up (odds ratio 1·02, 95% CI 0·99-1·06; p=0·19). We observed statistically significant heterogeneity in our model (Q=75·82, p=0·0011, I2=45%). Participant-level sensitivity analyses showed similar results in cohorts with a robust relative age effect at baseline and when restricting to cohorts involving children with a clinical diagnosis of ADHD or with a follow-up duration of more than 10 years.

INTERPRETATION

The diagnosis of ADHD in younger children in a class is no more likely to be disconfirmed over time than that of older children in the class. One interpretation is that the relative age effect decreases the likelihood of children of older relative age receiving a diagnosis of ADHD, and another is that assigning a diagnostic label of ADHD leads to unexplored carryover effects of the initial diagnosis that persist over time. Future studies should be conducted to explore these interpretations further.

FUNDING

None.

Behavioral self-regulation in pediatric bipolar disorder and healthy offspring of bipolar patients

OBJECTIVES

This study investigated behavioral self-regulation problems using the Children's Hostility Inventory (CHI) in pediatric bipolar disorder (PBD), healthy offspring of bipolar disorder patients (HOBD), and healthy controls (HC) without previous history of psychiatric disorders.

METHODS

The CHI was administered to 41 consecutive children and adolescents diagnosed with PBD, to 16 HOBD, and to 22 HC. The inventory assessed irritability, expression, hostility, and aggression and was completed by the children with the help of their mothers. Adolescents and their respective parents were interviewed separately using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL).

RESULTS

All subscales of the CHI presented statistically significant differences, except for the subscale assessing feelings of suspicion. Pairwise comparisons revealed consistently significant differences between the PBD group and controls, indicating more self-regulation difficulties in the PBD group, represented by high levels of hostility and aggressive behavior. There were no significant differences between the PBD and HOBD groups.

CONCLUSIONS

Future studies should further investigate if such behavior is state-dependent or a trait of bipolar juvenile expression. Expression of hostility and irritability should be considered relevant targets in psychosocial approaches addressing this population.

Use of Lithium in Pediatric Bipolar Disorders and Externalizing Childhood- related Disorders: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Lithium is the standard treatment for bipolar disorders (BD) in adults. There is a dearth of data on its use in the pediatric age. This review aimed to investigate the use of lithium in pediatric bipolar disorder (BD) and other externalizing childhood-related disorders.

METHODS

We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify randomized controlled trials evaluating the use of lithium in pediatric (BD), conduct disorder (CD), attention deficit hyperactivity disorder, oppositional defiant disorder, and disruptive mood dysregulation disorder. The primary outcome of our study was to evaluate the efficacy of lithium compared to a placebo or other pharmacological agents. The secondary outcomes were acceptability and tolerability.

RESULTS

Twelve studies were eligible, 8 on BD and 4 on CD. Overall, 857 patients were treated with lithium. No studies for externalizing disorder diagnoses were identified. Regarding BD patients (n = 673), efficacy results suggested that lithium was superior to placebo in manic/mixed episodes but inferior to antipsychotics. Lithium efficacy ranged from 32% to 82.4%. Results on maintenance need to be expanded. Comorbidity rates with other externalizing disorders were extremely high, up to 98.6%. Results in CD patients (n= 184) suggested the efficacy of lithium, especially for aggressive behaviors. No severe adverse events directly related to lithium were reported in BD and CD; common side effects were similar to adults.

CONCLUSION

This systematic review supports the use of lithium in BD and CD as an efficacious and generally well-tolerated treatment in the pediatric age. However, evidence is limited due to the paucity of available data.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Attention-Deficit/Hyperactivity Disorder Symptoms and Externalizing Progression in the LAMS Study: A Test of Trait Impulsivity Theory

OBJECTIVE

To test differential prospective prediction of growth in externalizing behavior, including oppositional defiant disorder, conduct disorder, and substance use disorders, by earlier hyperactive-impulsive (HI) vs inattentive (IN) symptoms of attention-deficit/hyperactivity disorder (ADHD).

METHOD

Participants in the Longitudinal Assessment of Manic Symptoms (LAMS) Study (N = 685 at study entry), including 458 boys and 227 girls ages 6-12, completed full parent report and self-report assessments every year for 8 years on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Three sets of analyses were conducted. First, hierarchal regression (block entry) was used to test independent associations between HI symptoms and later externalizing outcomes, controlling for IN symptoms, and IN symptoms and later externalizing outcomes, controlling for HI symptoms. Second, logistic regression was used to test progression of DSM externalizing disorders. Third, tests of mediation were used to assess potentiation of externalizing progression through environmental risk mediators (eg, family environment, neighborhood violence).

RESULTS

Consistent with hypotheses derived from trait impulsivity theories of externalizing behavior, HI symptoms of ADHD were associated independently with long-term externalizing outcomes, whereas IN symptoms were not. Between months 48 and 96, ADHD-HI/combined symptom subtype diagnoses predicted later oppositional defiant disorder diagnoses, oppositional defiant disorder diagnoses predicted later conduct disorder diagnoses, and conduct disorder diagnoses predicted later substance use disorder diagnoses. Evidence for environmental risk mediation (eg, parental monitoring, neighborhood violence) was also found.

CONCLUSION

Findings support trait impulsivity models of externalizing progression, whereby ADHD-HI/combined symptoms subtypes predispose to increasingly severe externalizing behaviors, which are magnified in contexts of environmental risk.

ADHD in Children and Adults: Diagnosis and Prognosis

Attention-Deficit Hyperactivity Disorder (ADHD) is a prevalent neuropsychiatric disorder associated with significant impairment and distress throughout the lifespan. Recent investigations have shed light on different aspects regarding the trajectory of ADHD, including reports on risk factors in childhood, that are associated with remission or persistence in adulthood. Despite significant advances in our understanding of the pathophysiology of the disorder, the diagnosis of ADHD remains strictly clinical and is based on behavioral symptoms of inattention, impulsivity, and hyperactivity. In this chapter we review the diagnostic process of ADHD, discuss the clinical presentation of the disorder across the lifespan, and examine patterns of comorbidity and longitudinal predictor of outcomes.

Attention Deficit Hyperactivity Disorder and Bipolar Disorder: Diagnosis, Treatments, and Clinical Considerations: A Narrative Review

Attention-deficit Hyperactivity Disorder is one of the most common childhood mental health disorders, affecting about 5.6% of the population worldwide. Several studies have specifically shown a high prevalence of comorbid mood disorders, such as depression and bipolar disorder (BD), in those diagnosed with ADHD. Several common symptoms of ADHD are also found in BD, which are characterized by alternating periods of euthymia and mood disturbances. The inattention and impulsivity of ADHD can be seen in manic and hypomanic episodes of BD. Over the past decade, there has been an increased interest in research between the correlation of ADHD and pediatric bipolar disorder (PBD) in children. Some experts hypothesize that more children are comorbidly diagnosed with ADHD and PBD because of how many clinicians treat children with ADHD. Other factors, which may affect the dual diagnoses of ADHD and PBD, are overlapping diagnostic criteria for the two disorders, the inevitable biases seen when one disorder is diagnosed without the other, and related risk factors leading to prodromal relationships. By examining clinical trials, a better understanding of whether ADHD and PBD have a stepwise progression or if other factors influence these comorbidities, such as blurred lines of diagnostic criteria. Those with ADHD are also at an increased risk of impairment at work and in social settings. This manuscript explores both progression of this disease and its clinical connections to other disorders.

Development of bipolar disorder in patients with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis of prospective studies

BACKGROUND

Increasing attention has been recently paid to precursors of bipolar disorder (BD). Symptoms of attention-deficit/hyperactivity disorder (ADHD) have been reported among the most common prodromes of BD. The aim of this study was to estimate the risk of BD in youths affected by ADHD based on prospective studies.

METHODS

A systematic review was conducted according to the PRISMA guidelines. A meta-analysis of single proportions was performed to compute the overall occurrence of BD in ADHD individuals. Binary outcome data were used to calculate risk estimates of BD occurrence in ADHD subjects versus Healthy Controls (HC).

RESULTS

An overall proportion of BD occurrence of 10.01% (95%-confidence interval [CI]: 6.47%-15.19%; I² = 82.0%) was found among 1248 patients with ADHD over 10 prospective studies. A slightly higher proportion was found when excluding one study based on jack-knife sensitivity analysis (11.96%, 95%-CI: 9.15%-15.49%; I² = 54.1%) and in three offspring studies (12.87%, 95%-CI: 8.91%-18.23%). BD occurrence was not significantly associated with mean follow-up duration (p-value = 0.2118). A greater risk of BD occurrence in ADHD versus HC from six studies was found (risk ratio: 8.97, 95%-CI: 4.26-18.87, p-value < 0.0001).

LIMITATIONS

Few prospective studies have been retrieved in our search and most were not specifically aimed at assessing BD in followed-up ADHD patients.

CONCLUSIONS

Greater clinical attention should be paid to ADHD as an early precursor of BD since a substantial proportion of ADHD patients is expected to be diagnosed with BD during the developmental age.

Psychiatric assessment

Studies have consistently reported an increased prevalence of psychiatric comorbidity (PC) in individuals with neurodevelopmental disorders (NDDs) compared with typically developing controls, with high rates of anxiety disorders in autism spectrum disorders and challenging behaviors in children and adolescent with intellectual disability. Psychiatric assessment in this population should include multiple sources of information, derived from multiple contexts and using multiple methods, with accurate detection of contributing and trigger factors. It is important to focus on detecting change from the child's baseline functioning and to use, when possible, ad hoc instruments for assessing PC in the NDD population. Modifications in the setting and assessment procedures should be scheduled based on the child's age, developmental level, and sensory sensitivities. Simultaneously, validated screening instruments, which dimensionally assess the symptomatology of several NDDs and psychiatric disorders, are warranted to not only assist in the identification of PCs in NDDs but also discriminate among different NDDs. Changes from DSM-IV-TR to DSM-5 have had an impact on the diagnosis of several disorders in children and adolescents and, subsequently, on the current diagnostic tools, requiring appropriate and prompt modifications of the available instruments.

Cingulum-Callosal white-matter microstructure associated with emotional dysregulation in children: A diffusion tensor imaging study

Emotional dysregulation symptoms in youth frequently predispose individuals to increased risk for mood disorders and other mental health difficulties. These symptoms are also known as a behavioral risk marker in predicting pediatric mood disorders. The underlying neural mechanism of emotional dysregulation, however, remains unclear. This study used the diffusion tensor imaging (DTI) technique to identify anatomically specific variation in white-matter microstructure that is associated with pediatric emotional dysregulation severity. Thirty-two children (mean age 9.53 years) with varying levels of emotional dysregulation symptoms were recruited by the Massachusetts General Hospital and underwent the DTI scans at Massachusetts Institute of Technology. Emotional dysregulation severity was measured by the empirically-derived Child Behavior Checklist Emotional Dysregulation Profile that includes the Attention, Aggression, and Anxiety/Depression subscales. Whole-brain voxel-wise regression tests revealed significantly increased radial diffusivity (RD) and decreased fractional anisotropy (FA) in the cingulum-callosal regions linked to greater emotional dysregulation in the children. The results suggest that microstructural differences in cingulum-callosal white-matter pathways may manifest as a neurodevelopmental vulnerability for pediatric mood disorders as implicated in the clinical phenotype of pediatric emotional dysregulation. These findings may offer clinically and biologically relevant neural targets for early identification and prevention efforts for pediatric mood disorders.

Development of bipolar disorder and other comorbidity among youth with attention-deficit/hyperactivity disorder

OBJECTIVE

To examine development of bipolar spectrum disorders (BPSD) and other disorders in prospectively followed children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

In the Longitudinal Assessment of Manic Symptoms (LAMS) study, 531 of 685 children age 6-12 (most selected for scores > 12 on General Behavior Inventory 10-item Mania scale) had ADHD, 112 with BPSD, and 419 without. With annual assessments for 8 years, retention averaged 6.2 years. Chi-square analyses compared rate of new BPSD and other comorbidity between those with versus without baseline ADHD and between retained versus resolved ADHD diagnosis. Cox regression tested factors influencing speed of BPSD onset.

RESULTS

Of 419 with baseline ADHD but not BPSD, 52 (12.4%) developed BPSD, compared with 16 of 110 (14.5%) without either baseline diagnosis. Those who developed BPSD had more nonmood comorbidity over the follow-up than those who did not develop BPSD (p = .0001). Of 170 who still had ADHD at eight-year follow-up (and not baseline BPSD), 26 (15.3%) had developed BPSD, compared with 16 of 186 (8.6%) who had ADHD without BPSD at baseline but lost the ADHD diagnosis (χ²  = 3.82, p = .051). There was no statistical difference in whether ADHD persisted or not across new BPSD subtypes (χ²  = 1.62, p = .446). Of those who developed BPSD, speed of onset was not significantly related to baseline ADHD (p = .566), baseline anxiety (p = .121), baseline depression (p = .185), baseline disruptive behavior disorder (p = .184), age (B = -.11 p = .092), maternal mania (p = .389), or paternal mania (B = .73, p = .056). Those who started with both diagnoses had more severe symptoms/impairment than those with later developed BPSD and reported having ADHD first.

CONCLUSIONS

In a cohort selected for symptoms of mania at age 6-12, baseline ADHD was not a significant prospective risk factor for developing BPSD. However, persistence of ADHD may marginally mediate risk of BPSD, and early comorbidity of both diagnoses increases severity/impairment.

Association of Genetic and Environmental Risks for Attention-Deficit/Hyperactivity Disorder With Hypomanic Symptoms in Youths

IMPORTANCE

Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder are highly comorbid, with significantly associated symptoms. The mechanisms that account for their co-occurrence are not known.

OBJECTIVE

To examine the degree to which genetic and environmental risk factors for ADHD traits, across childhood and adolescence, are associated with adolescent hypomanic symptoms.

DESIGN, SETTING, AND PARTICIPANTS

This study used data on 13 532 twin pairs from the Child and Adolescent Twin Study in Sweden, a prospective, longitudinal twin study. Their parents provided ADHD data when children were 9 or 12 years of age. Of those who reached 15 years of age, 3784 participated. Of those who reached 18 years of age, 3013 participated. The study was performed from December 20, 2017, to December 5, 2018. Data analysis was performed at the Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Stockholm, Sweden, from March 1, 2018, to October 31, 2018.

MAIN OUTCOMES AND MEASURES

Attention-deficit/hyperactivity disorder traits and hypomanic symptoms were assessed using parent-rated instruments. Associations between ADHD and adolescent hypomanic symptoms across childhood and adolescence were investigated using generalized estimating equations. Multivariate twin models were used to examine the extent to which genetic and environmental risk factors for ADHD were associated with hypomania.

RESULTS

Among 3784 15-year-old twin pairs and 3013 18-year-old twin pairs, ADHD and hypomanic symptoms were significantly associated (age 15 years: β = 0.30; 95% CI, 0.24-0.34; P < .001; age 18 years: β = 0.19; 95% CI, 0.16-0.22; P < .001), especially for the hyperactivity-impulsivity ADHD symptom domain (age 15 years: β = 0.53; 95% CI, 0.46-0.60; P < .001; age 18 years: β = 0.36; 95% CI, 0.30-0.42; P < .001) compared with the inattention domain (age 15 years: β = 0.40; 95% CI, 0.34-0.47; P < .001; age 18 years: β = 0.24; 95% CI, 0.19-0.29; P < .001). Between 13% and 29% of the genetic risk factors for hypomania were also associated with ADHD, with higher estimates detected for symptoms of hyperactivity-impulsivity (10%-25%) compared with inattention (6%-16%). Environmental factors played a negligible role in the associations. Genetic factors unique to adolescent hypomania were associated with 25% to 42% of its variance, suggesting some etiologic distinction between these forms of psychopathology.

CONCLUSIONS AND RELEVANCE

More than a quarter of the genetic risk factors for adolescent hypomanic traits were also associated with ADHD symptoms in childhood and adolescence, with hypomania-specific genetic risk factors detected. These findings suggest that ADHD and hypomanic symptoms are associated with shared genetic factors, which should be the focus of further research.

Attention deficit hyperactivity disorder and comorbidity: A review of literature

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with onset in early childhood. It is a clinically heterogenous condition with comorbidity posing a distinct challenge to diagnosing and managing these children and adolescents. This review aims to provide an overview of comorbidity with ADHD including other neurodevelopmental disorders, learning disorders, externalising and internalising disorders. Challenges in screening for, diagnosing and managing comorbidity with ADHD are summarised. Also, methodological challenges and future directions in research in this interesting field are highlighted.

Comorbid disorders as moderators of response to family interventions among adolescents with bipolar disorder

BACKGROUND

While family interventions have shown efficacy in improving mood symptoms and family functioning in pediatric bipolar disorder, few studies have examined the effects of comorbid psychiatric conditions on patients' symptomatic or functional responses to treatment.

METHODS

145 adolescents with bipolar I or II disorder were randomly assigned to family-focused therapy (FFT-A) or a brief psychoeducational therapy (enhanced care; EC) and followed over 2 years. Participants received pharmacotherapy for the study's duration. We examined whether comorbid anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders (DBDs; i.e., oppositional defiant and conduct disorder) predicted the proportion of weeks that participants experienced mood symptoms during follow-up, and whether comorbid disorders moderated the effects of treatment assignment on mood symptoms and family conflict.

RESULTS

Comorbid anxiety was associated with a greater proportion of weeks with depressive symptoms, more severe (hypo)manic symptoms during follow-up, and greater family conflict over the 2-year study. Comorbid ADHD was associated with a greater proportion of weeks with (hypo)manic symptoms, more severe (hypo)manic symptoms, and greater family conflict. Additionally, youth with comorbid ADHD who received FFT-A had more favorable trajectories of (hypo)manic symptoms and family functioning than youth with comorbid ADHD who received EC. Comorbid DBDs were consistently associated with more severe depressive symptoms and greater family conflict throughout the study.

LIMITATIONS

Randomization to treatments was not stratified on comorbid disorders. The longitudinal trajectories of anxiety, attentional, and disruptive behavior symptoms were not examined.

CONCLUSIONS

The course of bipolar disorder in adolescents is strongly affected by comorbid disorders. Future research should examine whether adolescents with more complex presentations of bipolar disorder should be treated with different or more intensive psychosocial protocols than adolescents without these presentations.

Longitudinal relationships among activity in attention redirection neural circuitry and symptom severity in youth

BACKGROUND

Changes in neural circuitry function may be associated with longitudinal changes in psychiatric symptom severity. Identification of these relationships may aid in elucidating the neural basis of psychiatric symptom evolution over time. We aimed to distinguish these relationships using data from the Longitudinal Assessment of Manic Symptoms (LAMS) cohort.

METHODS

Forty-one youth completed two study visits (mean=21.3 months). Elastic-net regression (Multiple response Gaussian family) identified emotional regulation neural circuitry that changed in association with changes in depression, mania, anxiety, affect lability, and positive mood and energy dysregulation, accounting for clinical and demographic variables.

RESULTS

Non-zero coefficients between change in the above symptom measures and change in activity over the inter-scan interval were identified in right amygdala and left ventrolateral prefrontal cortex. Differing patterns of neural activity change were associated with changes in each of the above symptoms over time. Specifically, from Scan1 to Scan2, worsening affective lability and depression severity were associated with increased right amygdala and left ventrolateral prefrontal cortical activity. Worsening anxiety and positive mood and energy dysregulation were associated with decreased right amygdala and increased left ventrolateral prefrontal cortical activity. Worsening mania was associated with increased right amygdala and decreased left ventrolateral prefrontal cortical activity. These changes in neural activity between scans accounted for 13.6% of the variance; that is 25% of the total explained variance (39.6%) in these measures.

CONCLUSIONS

Distinct neural mechanisms underlie changes in different mood and anxiety symptoms overtime.

Biography

Citation for Mary A. Fristad, recipient of the 2014 Bud Orgel Award for Distinguished Achievement in Research, from the Association of Psychologists in Academic Health Centers. Dr. Fristad has distinguished herself as an outstanding researcher, clinician, educator, and clinical administrator. She has published over 200 articles and chapters, and has been the Principal or Co-Principal Investigator for over two dozen federal, state, and other grants focused on assessment and treatment of mood disorders in children. In addition, Dr. Fristad is a founding member of the Board for Clinical Child and Adolescent Psychology of the American Board of Professional Psychology. She is an example to all psychologists working in medical settings through her contributions to our discipline and to the advancement of the science and treatment of child & adolescent psychopathology. Mary A. Fristad is truly a superb representative of the best our clinical psychological science has to offer.

Components of Motor Deficiencies in ADHD and Possible Interventions

There is a growing body of evidence pointing at several types of motor abnormalities found in attention-deficit/hyperactivity disorder (ADHD). In this article we review findings stemming from different paradigms, and suggest an interweaving approach to the different stages involved in the motor regulation process. We start by reviewing various aspects of motor abnormalities found in ADHD and related brain mechanisms. Then, we classify reported motor impairments associated with ADHD, into four classes of motor stages: Attention to the task, motion preparation, motion execution and motion monitoring. Motor abnormalities and corresponding neural activations are analyzed in the context of each of the four identified motor patterns, along with the interactions among them and with other systems. Given the specifications and models of the role of the four motor impairments in ADHD, we ask what treatments correspond to the identified motor impairments. We analyze therapeutic interventions targeting motor difficulties most commonly experienced among individuals with ADHD; first, Neurofeedback training and EMG-biofeedback. As some of the identified components of attention, planning and monitoring have been shown to be linked to abnormal oscillation patterns in the brain, we examine neurofeedback interventions aimed to address these types of oscillations: Theta/beta frequency training and SCP neurofeedback targeted at elevating the CNV component. Additionally we discuss EMG-Biofeedback interventions targeted at feedback on motor activity. Further we review physical activity and motor interventions aimed at improving motor difficulties, associated with ADHD. These kinds of interventions are shown to be helpful not only in aspects of physical ability, but also in enhancing cognition and executive functioning.

Affective responses across psychiatric disorders-A dimensional approach

Studying psychiatric disorders across nosological boundaries aims at a better understanding of mental disorders by identifying comprehensive signatures of core symptoms. Here, we studied neurobiological correlates of emotion processing in several major psychiatric disorders. We assessed differences between diagnostic groups, and investigated whether there is a psychopathological correlate of emotion processing that transcends disorder categories. 135 patient with psychiatric disorders (alcohol dependence, n=29; schizophrenia, n=37; major depressive disorder (MDD), n=25; acute manic episode of bipolar disorder, n=12; panic disorder, n=12, attention deficit/hyperactivity disorder (ADHD), n=20) and healthy controls (n=40) underwent an functional magnetic resonance imaging (fMRI) experiment with affectively positive, aversive and neutral pictures from the International Affective Picture System (IAPS). Between-group differences were assessed with full-factorial ANOVAs, with age, gender and smoking habits as covariates. Self-ratings of depressed mood and anxiety were correlated with activation clusters showing significant stimulus-evoked fMRI activation. Furthermore, we examined functional connectivity with the amygdala as seed region during the processing of aversive pictures. During the presentation of pleasant stimuli, we observed across all subjects significant activation of the ventromedial prefrontal cortex (vmPFC), bilateral middle temporal gyrus and right precuneus, while a significant activation of the left amygdala and the bilateral middle temporal gyrus was found during the presentation of aversive stimuli. We did neither find any significant interaction with diagnostic group, nor any correlation with depression and anxiety scores at the activated clusters or with amygdala connectivity. Positive and aversive IAPS-stimuli were consistently processed in limbic and prefrontal brain areas, irrespective of diagnostic category. A dimensional correlate of these neural activation patterns was not found.

Age associations with neural processing of reward anticipation in adolescents with bipolar disorders

Reward/behavioral approach system hypersensitivity is implicated in bipolar disorders (BD) and in normative development during adolescence. Pediatric onset of BD is associated with a more severe illness course. However, little is known about neural processing of rewards in adolescents with BD or developmental (i.e., age) associations with activation of these neural systems. The present study aims to address this knowledge gap. The present sample included 21 adolescents with BD and 26 healthy adolescents, ages 13 to 19. Participants completed a functional magnetic resonance imaging (fMRI) protocol using the Monetary Incentive Delay (MID) task. Behavioral performance was similar between groups. Group differences in BOLD activation during target anticipation and feedback anticipation periods of the task were examined using whole-brain analyses, as were group differences in age effects. During both target anticipation and feedback anticipation, adolescents with BD, compared to adolescents without psychopathology, exhibited decreased engagement of frontal regions involved in cognitive control (i.e., dorsolateral prefrontal cortex). Healthy adolescents exhibited age-related decreases, while adolescents with BD exhibited age-related increases, in activity of other cognitive control frontal areas (i.e., right inferior frontal gyrus), suggesting altered development in the BD group. Longitudinal research is needed to examine potentially abnormal development of cognitive control during reward pursuit in adolescent BD and whether early therapeutic interventions can prevent these potential deviations from normative development.

Can Emotional and Behavioral Dysregulation in Youth Be Decoded from Functional Neuroimaging?

INTRODUCTION

High comorbidity among pediatric disorders characterized by behavioral and emotional dysregulation poses problems for diagnosis and treatment, and suggests that these disorders may be better conceptualized as dimensions of abnormal behaviors. Furthermore, identifying neuroimaging biomarkers related to dimensional measures of behavior may provide targets to guide individualized treatment. We aimed to use functional neuroimaging and pattern regression techniques to determine whether patterns of brain activity could accurately decode individual-level severity on a dimensional scale measuring behavioural and emotional dysregulation at two different time points.

METHODS

A sample of fifty-seven youth (mean age: 14.5 years; 32 males) was selected from a multi-site study of youth with parent-reported behavioral and emotional dysregulation. Participants performed a block-design reward paradigm during functional Magnetic Resonance Imaging (fMRI). Pattern regression analyses consisted of Relevance Vector Regression (RVR) and two cross-validation strategies implemented in the Pattern Recognition for Neuroimaging toolbox (PRoNTo). Medication was treated as a binary confounding variable. Decoded and actual clinical scores were compared using Pearson's correlation coefficient (r) and mean squared error (MSE) to evaluate the models. Permutation test was applied to estimate significance levels.

RESULTS

Relevance Vector Regression identified patterns of neural activity associated with symptoms of behavioral and emotional dysregulation at the initial study screen and close to the fMRI scanning session. The correlation and the mean squared error between actual and decoded symptoms were significant at the initial study screen and close to the fMRI scanning session. However, after controlling for potential medication effects, results remained significant only for decoding symptoms at the initial study screen. Neural regions with the highest contribution to the pattern regression model included cerebellum, sensory-motor and fronto-limbic areas.

CONCLUSIONS

The combination of pattern regression models and neuroimaging can help to determine the severity of behavioral and emotional dysregulation in youth at different time points.

Bipolar Disorder Among Children and Adolescents

Although for years it was felt to be almost nonexistent, very-early-onset bipolar disorder (before age 12) has become an important member of the mood disorder spectrum of youths. Whether there is a separate subtype characterized by severe irritability or whether the problem of emotionally explosive children is better explained by other conditions is still being resolved. The diagnosis of bipolar I disorder requires an episode of mania, and understanding those manic symptoms is the source of differences in interpretation.

Risk for emerging bipolar disorder, variants, and symptoms in children with attention deficit hyperactivity disorder, now grown up

AIM: To determine the prevalence of bipolar disorder (BD) and sub-threshold symptoms in children with attention deficit hyperactivity disorder (ADHD) through 14 years’ follow-up, when participants were between 21-24 years old.

METHODS: First, we examined rates of BD type I and II diagnoses in youth participating in the NIMH-funded Multimodal Treatment Study of ADHD (MTA). We used the diagnostic interview schedule for children (DISC), administered to both parents (DISC-P) and youth (DISCY). We compared the MTA study subjects with ADHD (n = 579) to a local normative comparison group (LNCG, n = 289) at 4 different assessment points: 6, 8, 12, and 14 years of follow-ups. To evaluate the bipolar variants, we compared total symptom counts (TSC) of DSM manic and hypomanic symptoms that were generated by DISC in ADHD and LNCG subjects. Then we sub-divided the TSC into pathognomonic manic (PM) and non-specific manic (NSM) symptoms. We compared the PM and NSM in ADHD and LNCG at each assessment point and over time. We also evaluated the irritability as category A2 manic symptom in both groups and over time. Finally, we studied the irritability symptom in correlation with PM and NSM in ADHD and LNCG subjects.

RESULTS: DISC-generated BD diagnosis did not differ significantly in rates between ADHD (1.89%) and LNCG 1.38%). Interestingly, no participant met BD diagnosis more than once in the 4 assessment points in 14 years. However, on the symptom level, ADHD subjects reported significantly higher mean TSC scores: ADHD 3.0; LNCG 1.7; P < 0.001. ADHD status was associated with higher mean NSM: ADHD 2.0 vs LNCG 1.1; P < 0.0001. Also, ADHD subjects had higher PM symptoms than LNCG, with PM means over all time points of 1.3 ADHD; 0.9 LNCG; P = 0.0001. Examining both NSM and PM, ADHD status associated with greater NSM than PM. However, Over 14 years, the NSM symptoms declined and changed to PM over time (df 3, 2523; F = 20.1; P < 0.0001). Finally, Irritability (BD DSM criterion-A2) rates were significantly higher in ADHD than LNCG (χ² = 122.2, P < 0.0001), but irritability was associated more strongly with NSM than PM (df 3, 2538; F = 43.2; P < 0.0001).

CONCLUSION: Individuals with ADHD do not appear to be at significantly greater risk for developing BD, but do show higher rates of BD symptoms, especially NSM. The greater linkage of irritability to NSM than to PM suggests caution when making BD diagnoses based on irritability alone as one of 2 (A-level) symptoms for BD diagnosis, particularly in view of its frequent presentation with other psychopathologies.

Comorbidity of ADHD and subsequent bipolar disorder among adolescents and young adults with major depression: a nationwide longitudinal study

OBJECTIVES

Previous studies have found that attention-deficit hyperactivity disorder (ADHD) in childhood and adolescence is associated with an increased risk of major depression and bipolar disorder in later life. However, the effect of ADHD comorbidity on the diagnostic conversion to bipolar disorder among patients with major depression is still uncertain.

METHODS

Using the Taiwan National Health Insurance Research Database, 58,023 subjects < 30 years of age who had major depression with (n = 1,193) or without (n = 56,830) ADHD comorbidity between the years 2000 and 2008 were enrolled in our study. Subjects who developed bipolar disorder during the follow-up to the end of 2011 were identified.

RESULTS

Adolescents and young adults who had major depression with ADHD comorbidity had an increased incidence of subsequent bipolar disorder (18.9% versus 11.2%, p < 0.001) compared to those without ADHD. Cox regression analysis showed that ADHD comorbidity was an independent risk factor (hazard ratio = 1.50, 95% confidence interval 1.30-1.72) predicting subsequent bipolar disorder among those with major depression, adjusting for demographic data and psychiatric comorbidities.

CONCLUSIONS

Patients with comorbid diagnoses of major depression and ADHD had an increased risk of diagnostic conversion to bipolar disorder compared to those who had major depression alone. Further studies would be required to validate this finding and to investigate the possible underlying mechanisms.

White matter structure in youth with behavioral and emotional dysregulation disorders: a probabilistic tractographic study

IMPORTANCE

Psychiatric disorders in youth characterized by behavioral and emotional dysregulation are often comorbid and difficult to distinguish. An alternative approach to conceptualizing these disorders is to move toward a diagnostic system based on underlying pathophysiologic processes that may cut across conventionally defined diagnoses. Neuroimaging techniques have potentials for the identification of these processes.

OBJECTIVE

To determine whether diffusion imaging, a neuroimaging technique examining white matter (WM) structure, can identify neural correlates of emotional dysregulation in a sample of youth with different psychiatric disorders characterized by behavioral and emotional dysregulation.

DESIGN, SETTING, AND PARTICIPANTS

Using global probabilistic tractography, we examined relationships between WM structure in key tracts in emotional regulation circuitry (ie, cingulum, uncinate fasciculus, and forceps minor) and (1) broader diagnostic categories of behavioral and emotional dysregulation disorders (DDs) and (2) symptom dimensions cutting across conventional diagnoses in 120 youth with behavioral and/or emotional DDs, a referred sample of the Longitudinal Assessment of Manic Symptoms (LAM) study. Thirty age- and sex-matched typically developing youth (control participants) were included. Multivariate multiple regression models were used. The study was conducted from July 1, 2010, to February 28, 2014.

MAIN OUTCOMES AND MEASURES

Fractional anisotropy as well as axial and radial diffusivity were estimated and imported into a well-established statistical package. We hypothesized that (1) youth with emotional DDs and those with both behavioral and emotional DDs would show significantly lower fractional anisotropy compared with youth with behavioral DDs in these WM tracts and (2) that there would be significant inverse relationships between dimensional measures of affective symptom severity and fractional anisotropy in these tracts across all participants.

RESULTS

Multivariate multiple regression analyses revealed decreased fractional anisotropy and decreased axial diffusivity within the uncinate fasciculus in youth with emotional DDs vs those with behavioral DDs, those with both DDs, and the controls (F6,160 = 2.4; P = .032; all pairwise comparisons, P < .002). In the same model, greater severity of manic symptoms was positively associated with higher fractional anisotropy across all affected youth (F3,85 = 2.8; P = .044).

CONCLUSIONS AND RELEVANCE

These findings suggest that abnormal uncinate fasciculus and cingulum WM structure may underlie emotional, but not behavioral, dysregulation in pediatric psychiatric disorders and that a different neural mechanism may exist for comorbid emotional and behavioral DDs.

Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment

BACKGROUND

Research on pediatric bipolar disorder (PBD) is providing a plethora of empirical findings regarding its comorbidity. We addressed this question through a systematic review concerning the prevalence, clinical impact, etiology and treatment of main comorbid disorders involved.

METHOD

A comprehensive database search was performed from 1990 to August 2014. Overall, 167 studies fulfilled the inclusion criteria.

RESULTS

Bipolar youth tend to suffer from comorbid disorders, with highest weighted mean prevalence rate arising from anxiety disorders (54%), followed by attention deficit hyperactivity disorder (ADHD) (48%), disruptive behavior disorders (31%), and substance use disorders (SUD) (31%). Furthermore, evidence indicates that ADHD and anxiety disorders negatively affect the symptomatology, neurocognitive profile, clinical course and the global functioning of PBD. Likewise, several theories have been posited to explain comorbidity rates in PBD, specifically common risk factors, one disorder being a risk factor for the other and nosological artefacts. Lastly, randomized controlled trials highlight a stronger therapeutic response to stimulants and atomoxetine (vs. placebo) as adjunctive interventions for comorbid ADHD symptoms. In addition, research focused on the treatment of other comorbid disorders postulates some benefits from mood stabilizers and/or SGA.

LIMITATIONS

Epidemiologic follow-up studies are needed to avoid the risk of nosological artefacts. Likewise, more research is needed on pervasive developmental disorders and anxiety disorders, especially regarding their etiology and treatment.

CONCLUSIONS

Psychiatric comorbidity is highly prevalent and is associated with a deleterious clinical effect on pediatric bipolarity. Different etiological pathways may explain the presence of these comorbid disorders among bipolar youth. Standardized treatments are providing ongoing data regarding their effectiveness for these comorbidities among bipolar youth.

Diagnostic stability in pediatric bipolar disorder

BACKGROUND

The diagnostic stability of pediatric bipolar disorder has not been investigated previously. The aim was to investigate the diagnostic stability of the ICD-10 diagnosis of pediatric mania/bipolar disorder.

METHODS

All patients below 19 years of age who got a diagnosis of mania/bipolar disorder at least once in a period from 1994 to 2012 at psychiatric inpatient or outpatient contact in Denmark were identified in a nationwide register.

RESULTS

Totally, 354 children and adolescents got a diagnosis of mania/bipolar disorder at least once; a minority, 144 patients (40.7%) got the diagnosis at the first contact whereas the remaining patients (210; 59.3%) got the diagnosis at later contacts before age 19. For the latter patients, the median time elapsed from first treatment contact with the psychiatric service system to the first diagnosis with a manic episode/bipolar disorder was nearly 1 year and for 25% of those patients it took more than 2½ years before the diagnosis was made. The most prevalent other diagnoses than bipolar disorder at first contact were depressive disorder (21.4%), acute and transient psychotic disorders or other non-organic psychosis (19.2%), reaction to stress or adjustment disorder (14.8%) and behavioral and emotional disorders with onset during childhood or adolescents (10.9%). Prevalence rates of schizophrenia, personality disorders, anxiety disorder or hyperkinetic disorders (ADHD) were low.

LIMITATIONS

Data concern patients who get contact to hospital psychiatry only.

CONCLUSIONS

Clinicians should be more observant on manic symptoms in children and adolescents who at first glance present with transient psychosis, reaction to stress/adjustment disorder or with behavioral and emotional disorders with onset during childhood or adolescents (F90-98) and follow these patients more closely over time identifying putable hypomanic and manic symptoms as early as possible.

Decreased amygdala-insula resting state connectivity in behaviorally and emotionally dysregulated youth

The Research Domain Criteria (RDoC) adopts a dimensional approach for examining pathophysiological processes underlying categorically defined psychiatric diagnoses. We used this framework to examine relationships among symptom dimensions, diagnostic categories, and resting state connectivity in behaviorally and emotionally dysregulated youth selected from the Longitudinal Assessment of Manic Symptoms study (n=42) and healthy control youth (n=18). Region of interest analyses examined relationships among resting state connectivity, symptom dimensions (behavioral and emotional dysregulation measured with the Parent General Behavior Inventory-10 Item Mania Scale [PGBI-10M]; dimensional severity measures of mania, depression, anxiety), and diagnostic categories (Bipolar Spectrum Disorders, Attention Deficit Hyperactivity Disorder, Anxiety Disorders, and Disruptive Behavior Disorders). After adjusting for demographic variables, two dimensional measures showed significant inverse relationships with resting state connectivity, regardless of diagnosis: 1) PGBI-10M with amygdala-left posterior insula/bilateral putamen; and 2) depressive symptoms with amygdala-right posterior insula connectivity. Diagnostic categories showed no significant relationships with resting state connectivity. Resting state connectivity between amygdala and posterior insula decreased with increasing severity of behavioral and emotional dysregulation and depression; this suggests an intrinsic functional uncoupling of key neural regions supporting emotion processing and regulation. These findings support the RDoC dimensional approach for characterizing pathophysiologic processes that cut across different psychiatric disorders.

Distinguishing bipolar disorder from other psychiatric disorders in children

Pediatric onset bipolar disorder (BD) is a challenging diagnosis with potentially debilitating outcomes. This review aims to critically evaluate recently published literature relevant to the diagnosis of BD in youth, emphasizing interesting and important new findings characterizing pediatric BD and reporting updates in the diagnostic and statistical manual relevant to this disorder in youth. Challenges regarding the diagnosis of BD will be discussed, in addition to important distinctions with other childhood disorders, including other bipolar spectrum disorders; major depressive disorder; dysthymia; disruptive mood dysregulation disorder (DMDD); attention-deficit/hyperactivity disorder (ADHD) and other disruptive behavioral disorders; anxiety disorders, including post-traumatic stress disorder (PTSD); psychotic disorders; autism spectrum disorders; substance use disorders; and borderline personality disorder. The review concludes with a comment on past research limitations and future directions in the field.

Correlates of psychiatric hospitalization in a clinical sample of Canadian adolescents with bipolar disorder

OBJECTIVE

To identify factors associated with psychiatric hospitalization among adolescents with bipolar disorder (BD).

METHODS

Participants were 100 adolescents, ages 13-19, who fulfilled DSM-IV criteria for bipolar I disorder [(BD-I), n=26], bipolar II disorder [(BD-II), n=40], or operationalized criteria for BD not otherwise specified [(BD-NOS), n=34], via the Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version (KSADS-PL). Demographic, clinical, and family history variables were measured via clinical interview with the participant and a parent or guardian.

RESULTS

The lifetime prevalence of psychiatric hospitalization was 50%. Significant predictors of psychiatric hospitalization in univariate analyses included older age, BD-I, history of suicide attempt, psychosis, lifetime use of second generation antipsychotics (SGAs), lithium, SSRI antidepressants and any medication. BD-II was negatively associated with psychiatric hospitalization. In multivariable analyses, older age, history of suicide attempt, psychosis and use of SGAs were positively associated with hospitalization, whereas BD-II was negatively associated with hospitalization.

CONCLUSIONS

Psychiatric hospitalization in adolescents with BD is highly prevalent and associated with older age and proxies for greater illness severity. Further studies are needed to identify strategies for reducing the need for psychiatric hospitalizations among adolescents with BD.

Three-year latent class trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD

OBJECTIVE

This study aims to examine trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms in the Longitudinal Assessment of Manic Symptoms (LAMS) sample.

METHOD

The LAMS study assessed 684 children aged 6 to 12 years with the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) and rating scales semi-annually for 3 years. Although they were selected for elevated manic symptoms, 526 children had baseline ADHD diagnoses. With growth mixture modeling (GMM), we separately analyzed inattentive and hyperactive/impulsive symptoms, covarying baseline age. Multiple standard methods determined optimal fit. The χ(2) and Kruskal-Wallis analysis of variance compared resulting latent classes/trajectories on clinical characteristics and medication.

RESULTS

Three latent class trajectories best described inattentive symptoms, and 4 classes best described hyperactive/impulsive symptoms. Inattentive trajectories maintained their relative position over time. Hyperactive/impulsive symptoms had 2 consistent trajectories (least and most severe). A third trajectory (4.5%) started mild, then escalated; and a fourth (14%) started severe but improved dramatically. The improving trajectory was associated with the highest rate of ADHD and lowest rate of bipolar diagnoses. Three-fourths of the mildest inattention class were also in the mildest hyperactive/impulsive class; 72% of the severest inattentive class were in the severest hyperactive/impulsive class, but the severest inattention class also included 62% of the improving hyperactive-impulsive class.

CONCLUSION

An ADHD rather than bipolar diagnosis prognosticates a better course of hyperactive/impulsive, but not inattentive, symptoms. High overlap of relative severity between inattention and hyperactivity/impulsivity confirms the link between these symptom clusters. Hyperactive/impulsive symptoms wane more over time. Group means are insufficient to understand individual ADHD prognosis. A small subgroup deteriorates over time in hyperactivity/impulsivity and needs better treatments than currently provided.

[Bipolar disorder in children and adolescents: a difficult diagnosis]

Bipolar disorder (BD) is a severe mental condition with neurodevelopmental features that clinically results in pathological fluctuations of mood. Whereas it was classically or traditionally considered as an adult-onset disorder, recent findings suggest that BD may occur very early in the life course, thus, determining what is now called Juvenile bipolar disorder (JBD). One of the reasons for which JBD has been so difficult to identify is that JBD primary symptoms vary much from the typical adulthood BD clinical expression. Euphoric mood is rare in JBD, while irritability mood, aggressive temper, mixed manic state onset, rapid cycling, anger outbursts and chronic course of symptoms are much more frequent. This specific clinical presentation makes JBD difficult to differentiate from other diagnoses related to pathological externalizing behaviours, including conduct disorder, oppositional provocative disorder, and attention deficit-hyperactivity disorder.

How to Understand Divergent Views on Bipolar Disorder in Youth

There are two divergent viewpoints on the phenomenology and outcome of bipolar I (BP I) disorder in youth. Disparities evolved as unintended consequences from investigators' inconsistencies both in translating the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-III-R, and DSM-IV criteria and in operationalizing them differently in their standardized assessments. Rates of conservatively diagnosed BP I are lower both in community studies of youths than in adults and from liberally defined BP I in youths. Rates of co-occurring attention-deficit hyperactivity disorder (ADHD) are lower in conservatively than liberally defined children and adolescents with BP I. Rates of both BP I and of ADHD are lower in offspring of BP I probands, and outcome more closely approximates that of adults with BP I in conservatively versus liberally defined children and teens with BP I. Both perspectives can claim evidence for reliability and validity that support their positions. However, the samples are so different that it is difficult to compare studies conducted from these different perspectives.

Hypomania spectrum disorder in adolescence: a 15-year follow-up of non-mood morbidity in adulthood

BACKGROUND

We investigated whether adolescents with hypomania spectrum episodes have an excess risk of mental and physical morbidity in adulthood, as compared with adolescents exclusively reporting major depressive disorder (MDD) and controls without a history of adolescent mood disorders.

METHODS

A community sample of adolescents (N = 2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes (40 full-syndromal, 18 with brief episode, and 32 subsyndromal), while another 197 fulfilled the criteria for MDD without a history of a hypomania spectrum episode. A follow up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. The participation rate at the follow-up interview was 71% (64/90) for the hypomania spectrum group, and 65.9% (130/197) for the MDD group. Multiple imputation was used to handle missing data.

RESULTS

The outcomes of the hypomania spectrum group and the MDD group were similar regarding subsequent non-mood Axis I disorders in adulthood (present in 53 vs. 57%). A personality disorder was reported by 29% of the hypomania spectrum group and by 20% of the MDD group, but a statistically significant difference was reached only for obsessive-compulsive personality disorder (24 vs. 14%). In both groups, the risk of Axis I disorders and personality disorders in adulthood correlated with continuation of mood disorder. Prescription drugs and health service use in adulthood was similar in the two groups. Compared with adolescents without mood disorders, both groups had a higher subsequent risk of psychiatric morbidity, used more mental health care, and received more psychotropic drugs.

CONCLUSIONS

Although adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes, both groups are at increased risk for subsequent mental health problems. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course.

Parsing dimensional vs diagnostic category-related patterns of reward circuitry function in behaviorally and emotionally dysregulated youth in the Longitudinal Assessment of Manic Symptoms study

IMPORTANCE

Pediatric disorders characterized by behavioral and emotional dysregulation pose diagnostic and treatment challenges because of high comorbidity, suggesting that they may be better conceptualized dimensionally rather than categorically. Identifying neuroimaging measures associated with behavioral and emotional dysregulation in youth may inform understanding of underlying dimensional vs disorder-specific pathophysiologic features.

OBJECTIVE

To identify, in a large cohort of behaviorally and emotionally dysregulated youth, neuroimaging measures that (1) are associated with behavioral and emotional dysregulation pathologic dimensions (behavioral and emotional dysregulation measured with the Parent General Behavior Inventory 10-Item Mania Scale [PGBI-10M], mania, depression, and anxiety) or (2) differentiate diagnostic categories (bipolar spectrum disorders, attention-deficit/hyperactivity disorder, anxiety, and disruptive behavior disorders).

DESIGN, SETTING, AND PARTICIPANTS

A multisite neuroimaging study was conducted from February 1, 2011, to April 15, 2012, at 3 academic medical centers: University Hospitals Case Medical Center, Cincinnati Children's Hospital Medical Center, and University of Pittsburgh Medical Center. Participants included a referred sample of behaviorally and emotionally dysregulated youth from the Longitudinal Assessment of Manic Symptoms (LAMS) study (n = 85) and healthy youth (n = 20).

MAIN OUTCOMES AND MEASURES

Region-of-interest analyses examined relationships among prefrontal-ventral striatal reward circuitry during a reward paradigm (win, loss, and control conditions), symptom dimensions, and diagnostic categories.

RESULTS

Regardless of diagnosis, higher PGBI-10M scores were associated with greater left middle prefrontal cortical activity (r = 0.28) and anxiety with greater right dorsal anterior cingulate cortical (r = 0.27) activity to win. The 20 highest (t = 2.75) and 20 lowest (t = 2.42) PGBI-10M-scoring youth showed significantly greater left middle prefrontal cortical activity to win compared with 20 healthy youth. Disruptive behavior disorders were associated with lower left ventrolateral prefrontal cortex activity to win (t = 2.68) (all P < .05, corrected).

CONCLUSIONS AND RELEVANCE

Greater PGBI-10M-related left middle prefrontal cortical activity and anxiety-related right dorsal anterior cingulate cortical activity to win may reflect heightened reward sensitivity and greater attention to reward in behaviorally and emotionally dysregulated youth regardless of diagnosis. Reduced left ventrolateral prefrontal cortex activity to win may reflect reward insensitivity in youth with disruptive behavior disorders. Despite a distinct reward-related neurophysiologic feature in disruptive behavior disorders, findings generally support a dimensional approach to studying neural mechanisms in behaviorally and emotionally dysregulated youth.

Comparing tomographic EEG neurofeedback and EMG biofeedback in children with attention-deficit/hyperactivity disorder

Two types of biofeedback (BF), tomographic electroencephalogram (EEG) neurofeedback (NF) and electromyographic biofeedback (EMG-BF), both with phasic and tonic protocols, were compared for treatment effects and specificity in attention-deficit/hyperactivity disorder (ADHD). Thirteen children with ADHD trained their brain activity in the anterior cingulate cortex (ACC), and twelve trained activity of arm muscles involved in fine motor skills. In each training session, resting state 24-channel EEG and training performances were recorded. Both groups showed similar behavioral improvements and artifact reduction in selected conditions, with no significant advantages despite medium effect sizes on primary outcomes for NF. Only the EMG-BF group, however, showed clear improvement in training regulation performance, and specific motor coordination effects. The NF group tended to present individual normalization of trained frequency bands in the ACC during rest across training. The results provide evidence for some specific effects in our small sample, albeit only to a small extent.

Comparison of aripiprazole and other atypical antipsychotics for pediatric bipolar disorder: a retrospective chart review of efficacy and tolerability

Objective

This study compared the efficacy and tolerability of aripiprazole with that of other atypical antipsychotics by examining patients with pediatric bipolar disorder (PBD) at a child and adolescent psychiatric clinic in a university hospital in Korea.

Methods

We reviewed the medical records of 127 pediatric patients with bipolar disorder aged 4-18 years treated at Department of Child and Adolescent Psychiatric, Yonsei University Severance Hospital between January 2010 and October 2011 to collect demographic and clinical data. Using the Clinical Global Impression (CGI) scales, we evaluated levels of severity of and improvements in symptoms at the first, second, third, fourth, and fifth hospital visits.

Results

The mean age of patients was 12.29±3.47 years. The sample included 91 (71.7%) male and 36 (28.3%) female patients. Aripiprazole was prescribed to 62 (48.8%) patients, risperidone to 52 (40.9%), quetiapine to 11 (8.7%), and paliperidone to two (1.6%). Patients treated with aripiprazole had lower CGI-Severity (CGI-S) scores than did patients treated with other atypical antipsychotics at the second and third visits. The CGI-Improvement (CGI-I) scores of patients treated with aripiprazole were lower at the second visit. Treatment with atypical antipsychotics was well tolerated, and no serious or fatal side effects were observed.

Conclusion

The present retrospective chart review suggests that atypical antipsychotics may be effective and safe for the treatment of patients with PBD. In particular, treatment with aripiprazole may be more effective than treatment with other atypical antipsychotics in the early phase. These results should be verified in future multi-center controlled studies.

The comorbidity of ADHD and bipolar disorder: any less confusion?

The clinical confusion surrounding childhood ADHD and bipolar disorder centers on overlaps between severe ADHD with mood lability and mania/hypomania. Perplexity has been exacerbated by the removal of mood symptoms from the diagnostic criteria for ADHD and a lack of stringent criteria for a manic/hypomanic episode. This review summarizes current knowledge of the relationship between ADHD and bipolar disorder, the rates with which ADHD and bipolar disorder coexist in youth of differing ages, their presence in community, clinical, and high risk samples, and their longitudinal course. Treatment studies are reviewed, highlighting findings in comorbid cases, which support the efficacy of stimulants and other agents for ADHD without worsening mood symptoms, and efficacy of second generation antipsychotics for bipolar disorder. In conclusion, a lack of clarity regarding the diagnostic boundaries between childhood ADHD and bipolar disorder remains, however, treatments targeting symptoms of each disorder when comorbid, provide some efficacy.

Comorbidity of attention-deficit/hyperactivity disorder and bipolar disorder in North Indian clinic children and adolescents

OBJECTIVE

This study examined comorbidity between attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BPD) in children attending child and adolescent psychiatry (CAP) services in a Medical University in North India.

METHODS

Children attending CAP services, old or new, were assessed using unstructured clinical interview, kiddie-Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime Version (K-SADS-PL), Mental State Examination (MSE) for ADHD, Child Mania Rating Scale (CMRS) Parent Version and Children's Global Assessment Scale (C-GAS). Information was collected from both children and parents. All children were clinically evaluated, and prospectively followed up. The diagnosis was made by consensus. Subjects with DSM-IV-TR diagnosis of ADHD, BPD, and ADHD+BPD were compared with each other. Research criteria for broad phenotype BPD were applied in ADHD subjects without DSM-IV-TR diagnosis of BPD.

RESULTS

45 subjects had ADHD; 21, BPD and; 7 had lifetime DSM-IV-TR diagnosis of ADHD+BPD. 13.5% of ADHD subjects had comorbid BPD and 25% of BPD subjects had comorbid ADHD. ADHD-CT was the most common subtype of ADHD. Nearly two third of BPD subjects had their first mood episode before 13 years of age. ADHD+BPD subjects were more likely to be mentally retarded and have longer duration of mood episode compared to BPD subjects. Three subjects with DSM-IV-TR diagnosis of ADHD without BPD were additionally diagnosed with broad phenotype of BPD.

CONCLUSIONS

Variable comorbidity rates of ADHD+BPD in different studies are most likely due to differences in study setting, study sample, conceptualization of BPD and assessment methods.

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.

Pediatric bipolar disorder and ADHD: family history comparison in the LAMS clinical sample

BACKGROUND

Transgenerational association of bipolar spectrum disorder (BPSD) and attention deficit/hyperactivity disorder (ADHD) has been reported, but inconclusively.

METHOD

Children ages 6-12 were systematically recruited at first outpatient visit at 9 clinics at four universities and reliably diagnosed; 621 had elevated symptoms of mania (>12 on the Parent General Behavior Inventory 10-Item Mania Scale); 86 had scores below 12. We analyzed baseline data to test a familial association hypothesis: compared to children with neither BPSD nor ADHD, those with either BPSD or ADHD would have parents with higher rates of both bipolar and ADHD symptoms, and parents of comorbid children would have even higher rates of both.

RESULTS

Of 707 children, 421 had ADHD without BPSD, 45 BPSD without ADHD, 117 comorbid ADHD+BPSD, and 124 neither. The rate of parental manic symptoms was similar for the comorbid and BPSD-alone groups, significantly greater than for ADHD alone and "neither" groups, which had similar rates. ADHD symptoms in parents of children with BPSD alone were significantly less frequent than in parents of children with ADHD (alone or comorbid), and no greater than for children with neither diagnosis. Family history of manic symptoms, but not ADHD symptoms, was associated with parent-rated child manic-symptom severity over and above child diagnosis.

LIMITATIONS

The sample was not epidemiologic, parent symptoms were based on family history questions, and alpha was 0.05 despite multiple tests.

CONCLUSIONS

These results do not support familial linkage of BPSD and ADHD; they are compatible with heritability of each disorder separately with coincidental overlap.

An update on the debated association between ADHD and bipolar disorder across the lifespan

Diagnostic formulations for attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BD) both include symptoms of distractibility, psychomotor agitation and talkativeness, alongside associated emotional features (irritability and emotional lability). Treatment studies suggest the importance of accurate delineation of ADHD and BD. However, boundaries between the two disorders are blurred by the introduction of broader conceptualisations of BD. This review attempts to elucidate whether associations between ADHD and BD are likely to be driven by superficial symptomatological similarities or by a more meaningful etiological relationship between the disorders. This is achieved by outlining findings on comorbidity, temporal progression of the disorders, familial co-variation, and neurobiology in ADHD and BD across the lifespan. Longitudinal studies fail to consistently show developmental trajectories between ADHD and BD. Comparative research investigating neurobiology is in its infancy, and although some similarities are seen between ADHD and BD, studies also emphasise differences between the two disorders. However, comorbidity and family studies appear to show that the two disorders occur together and aggregate in families at higher than expected rates. Furthermore close inspection of results from population studies reveals heightened co-occurrence of ADHD and BD even in the context of high comorbidity commonly noted in psychopathology. These results point towards a meaningful association between ADHD and BD, going beyond symptomatic similarities. However, future research needs to account for heterogeneity of BD, making clear distinctions between classical episodic forms of BD, and broader conceptualisations of the disorder characterised by irritability and emotional lability, when evaluating the relationship with ADHD.

Differential diagnosis of bipolar disorder in children and adolescents

Issues complicating the differential diagnosis of bipolar disorder in young people are discussed. They include: a) the subtype of bipolar disorder being considered; b) the person's age and stage of development; c) whether one views bipolar disorder more conservatively, requiring clear episodes that mark a distinct change from premorbid levels of function, or more liberally, focusing for instance on severe irritability/explosive outbursts as the mood change; d) who is reporting manic symptoms, and whether symptoms are past and must be recalled or current and more likely to be observed; e) impact of family history. The diagnosis of mania/bipolar I disorder may not become clear for a number of years. This is an impairing disorder, but so are the conditions from which it must be distinguished. Family history may increase the odds that certain symptoms/behaviors are manifestations of bipolar disorder but it does not make the diagnosis. Until there are biomarkers that can confirm the diagnosis, and treatments unique to the condition, it is wise to make a diagnosis of bipolar disorder in children and adolescents provisionally and keep an open mind to the likelihood that revisions may be necessary.