Characteristics of children with elevated symptoms of mania: the Longitudinal Assessment of Manic Symptoms (LAMS) study

The stability and persistence of symptoms in childhood-onset ADHD

The course of childhood-onset attention deficit hyperactivity disorder (ADHD) varies across individuals; some will experience persistent symptoms while others' symptoms fluctuate or remit. We describe the longitudinal course of ADHD symptoms and associated clinical characteristics in adolescents with childhood-onset ADHD. Participants (aged 6-12 at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study who met DSM criteria for ADHD prior to age 12 were evaluated annually with the Kiddie Schedule for Affective Disorders and Schizophrenia for eight years. At each timepoint, participants were categorized as meeting ADHD criteria, subthreshold criteria, or not having ADHD. Stability of course was defined by whether participants experienced consistent ADHD symptoms, fluctuating symptoms, or remission. The persistence of the symptoms was defined by symptom status at the final two follow-ups (stable ADHD, stable remission, stable partial remission, unstable). Of 685 baseline participants, 431 had childhood-onset ADHD and at least two follow-ups. Half had a consistent course of ADHD, nearly 40% had a remitting course, and the remaining participants had a fluctuating course. More than half of participants met criteria for ADHD at the end of their participation; about 30% demonstrated stable full remission, 15% had unstable symptoms, and one had stable partial remission. Participants with a persistent course and stable ADHD outcome reported the highest number of symptoms and were most impaired. This work builds on earlier studies that describe fluctuating symptoms in young people with childhood-onset ADHD. Results emphasize the importance of ongoing monitoring and detailed assessment of factors likely to influence course and outcome to help young people with childhood-onset ADHD.

Adequacy of Children's Psychopharmacology Services: Variations by Race and Clinical Characteristics

OBJECTIVE

An expert consensus approach was used to determine the adequacy of children's psychopharmacology and to examine whether adequacy varied by demographic or clinical characteristics.

METHODS

Data were from the baseline interview of 601 children, ages 6-12 years, who had visited one of nine outpatient mental health clinics and participated in the Longitudinal Assessment of Manic Symptoms study. Children and parents were interviewed with the Kiddie Schedule for Affective Disorders and Schizophrenia and the Service Assessment for Children and Adolescents to assess the child's psychiatric symptoms and lifetime mental health services use, respectively. An expert consensus approach informed by published treatment guidelines was used to determine the adequacy of children's psychotropic medication treatment.

RESULTS

Black children (compared with White children; OR=1.84, 95% CI=1.53-2.23) and those with anxiety disorders (vs. no anxiety disorder; OR=1.55, 95% CI=1.08-2.20) were more likely to receive inadequate pharmacotherapy; those whose caregivers had a bachelor's degree or more education (vs. those who had a high school education, general equivalency diploma, or less than high school education; OR=0.74, 95% CI=0.61-0.89) were less likely to receive inadequate pharmacotherapy.

CONCLUSIONS

The consensus rater approach permitted use of published treatment efficacy data and patient characteristics (e.g., age, diagnoses, history of recent hospitalizations, and psychotherapy) to assess adequacy of pharmacotherapy. These results replicate findings of racial disparities reported in previous research using traditional methods to determine treatment adequacy (e.g., with a minimum number of treatment sessions) and highlight the continued need for research on racial disparities and strategies to improve access to high-quality care.

Reorienting Latent Variable Modeling for Supervised Learning

Despite its potentials benefits, using prediction targets generated based on latent variable (LV) modeling is not a common practice in supervised learning, a dominating framework for developing prediction models. In supervised learning, it is typically assumed that the outcome to be predicted is clear and readily available, and therefore validating outcomes before predicting them is a foreign concept and an unnecessary step. The usual goal of LV modeling is inference, and therefore using it in supervised learning and in the prediction context requires a major conceptual shift. This study lays out methodological adjustments and conceptual shifts necessary for integrating LV modeling into supervised learning. It is shown that such integration is possible by combining the traditions of LV modeling, psychometrics, and supervised learning. In this interdisciplinary learning framework, generating practical outcomes using LV modeling and systematically validating them based on clinical validators are the two main strategies. In the example using the data from the Longitudinal Assessment of Manic Symptoms (LAMS) Study, a large pool of candidate outcomes is generated by flexible LV modeling. It is demonstrated that this exploratory situation can be used as an opportunity to tailor desirable prediction targets taking advantage of contemporary science and clinical insights.

Characteristics prior to and at time of diagnosis in pediatric bipolar disorder

OBJECTIVES

Describe symptoms before and at time of register-diagnosis in children and adolescents.

METHODS

A random sample was selected for chart-review from a Danish nationwide cohort of patients <18 years registered with an incident ICD-10 register-diagnosis of single hypomanic/manic episode or bipolar disorder between 1995 and 2014. Patients with symptoms which adequately documented a BD diagnosis in the chart were included for analysis.

RESULTS

521 were diagnosed in the study period. A random sample of 25% were selected, and 106 charts were possible to retrieve, with 48 chart reviews resulting in confirmation of diagnosis. Time from first reported affective symptoms to diagnosis was 2.6 ± 2.7 years for depressive symptoms, 2.5 ± 2.9 years for mixed symptoms, 1.4 ± 1.6 years for hypomanic symptoms, and 0.4 ± 0.5 years for manic symptoms. A hierarchical clustering analysis revealed three patient-profiles: primarily hypomanic/manic, primarily depressive, and more rare, primarily mixed profile. Frequently reported symptoms prior to diagnosis include anhedonia (79%), irritability (71%), hyperactivity (62.5%), decreased energy (62.5%), and psychotic symptoms (52%).Symptoms of ADHD (19%), comorbid ADHD (15%), symptoms of anxiety (52%), comorbid anxiety (4%), suicidal thoughts (50%), suicide attempts (8%), cutting (23%), substance misuse (21%), and criminal activity (10%) were reported before incident BD diagnosis.

CONCLUSION

The observed patient-profiles leading to diagnosis were primarily manic or depressive, resembling presentations in adults. The presence of ADHD, anxiety, suicide attempts, cutting, and criminal activity prior to diagnosis emphasizes the need for treatment of children and adolescents with affective symptoms. The gap from appearance of the symptoms to diagnosis suggests a window for earlier treatment.

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.

Generalizing the Prediction of Bipolar Disorder Onset Across High-Risk Populations

OBJECTIVE

Risk calculators (RC) to predict clinical outcomes are gaining interest. An RC to estimate risk of bipolar spectrum disorders (BPSD) could help reduce the duration of undiagnosed BPSD and improve outcomes. Our objective was to adapt an RC previously validated in the Pittsburgh Bipolar Offspring Study (BIOS) sample to achieve adequate predictive ability in both familial high-risk and clinical high-risk youths.

METHOD

Participants (aged 6-12 years at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study (N = 473) were evaluated semi-annually. Evaluations included a Kiddie Schedule for Affective Disorders (K-SADS) interview. After testing an RC that closely approximated the original, we made modifications to improve model prediction. Models were trained in the BIOS data, which included biennial K-SADS assessments, and tested in LAMS. The final model was then trained in LAMS participants, including family history of BPSD as a predictor, and tested in the familial high-risk sample.

RESULTS

Over follow-up, 65 youths newly met criteria for BPSD. The original RC identified youths who developed BPSD only moderately well (area under the curve [AUC] = 0.67). Eliminating predictors other than the K-SADS screening items for mania and depression improved accuracy (AUC = 0.73) and generalizability. The model trained in LAMS, including family history as a predictor, performed well in the BIOS sample (AUC = 0.74).

CONCLUSION

The clinical circumstances under which the assessment of symptoms occurs affects RC accuracy; focusing on symptoms related to the onset of BPSD improved generalizability. Validation of the RC under clinically realistic circumstances will be an important next step.

Dietary Consumption Among Youth with Antipsychotic-Induced Weight Gain and Changes Following Healthy Lifestyle Education

Background: Youth treated with antipsychotic medications are high risk for weight gain, increased lipids/glucose, and development of metabolic syndrome. Little is known about the dietary intake/nutritional adequacy in this vulnerable population, and effect on weight gain. This secondary data analysis describes the baseline intake and changes in diet after receiving healthy lifestyle education/counseling over 6 months, in a sample of youth with antipsychotic-induced weight gain. Methods: The U.S. Department of Agriculture (USDA) Automated Multiple-Pass Method 24-hour dietary recall was administered to 117 youth at baseline, 3 months, and 6 months. Parent/child received personalized healthy lifestyle education sessions over 6 months. Baseline intake was compared with the USDA Recommended Daily Allowance using independent samples t-tests. Individual dietary covariates were examined for change over 6 months using longitudinal linear mixed modeling. Influence of each on body mass index (BMI) z-score change was tested in a pooled group analysis and then compared by treatment group. Results: Pooled analysis revealed baseline consumption high in carbohydrates, fat, protein, sugar, and refined grains, while low in fruit/vegetables, whole grains, fiber, and water. Change over 6 months demonstrated a statistically significant decrease in daily calories (p = 0.002), carbohydrates (p = 0.003), fat (p = 0.012), protein (p = 0.025), sugar (p = 0.008), refined grains (p = 0.008), total dairy (p = 0.049), and cheese (p = 0.027). Small increases in fruits/vegetables were not statistically significant, although the Healthy Eating Index subscores for total vegetables (p = 0.013) and dark green/orange vegetables (p = 0.034) were. No dietary covariates were predictors of change in BMI z-score. Nondietary predictors were parent weight/BMI and treatment group, with the metformin and switch groups experiencing significant decreases in BMI z-score. Conclusions: Further pediatric studies are necessary to assess the effects of antipsychotic medications on dietary intake, and test efficacy of healthy lifestyle interventions on change in nutrition. The relationship of nutrition to cardiometabolic health in this population must be further investigated. Clinical Trial Registration number: NCT02877823.

Moody kids years later: Long-term outcomes of youth from the Omega-3 and therapy (OATS) studies

BACKGROUND

This naturalistic follow-up study examines outcomes for youth with depression (n = 25) or subsyndromal bipolar disorder (n = 13) 2-5 years after participation in randomized clinical trials (RCTs) of omega-3 fatty acids (Ω3), individual family psychoeducational psychotherapy (IF-PEP), and their combination METHODS: Forty percent (38/95) of RCT families completed a follow-up assessment RESULTS: Relapse rates and conversion to bipolar disorder were consistent with published literature. Original treatment assignment did not impact current functioning. Overall, participants' mood severity, executive functioning, and global functioning continued to be better than at RCT baseline. Depressive symptoms increased significantly from end of RCT. Manic symptom severity, executive functioning, and global functioning remained comparable to end of RCT. The majority of parents and youth reported improved youth emotion regulation skills and family communication. They considered study participation beneficial, with increased understanding of mood disorders being the top reason. Half of youth commenced or continued Ω3 and 58% commenced or continued psychotherapy post-RCT, suggesting some degree of consumer satisfaction; these youth had lower depression severity than other participants.

LIMITATIONS

Only 40% returned to this naturalistic follow-up; they were less likely to have an African-American parent, were of higher income, and youth were more symptomatic at end of RCT than those who did not return CONCLUSIONS: Improvement from RCT baseline continued although depressive symptom severity increased from end of RCT to follow-up. Meaningful improvements in youth and family functioning persisted 2-5 years later. Interventions that prevent relapse or conversion to BPSD are still needed for these vulnerable populations.

Predictors of Hospitalization in a Cohort of Children with Elevated Symptoms of Mania

Describe hospitalization rates in children with elevated symptoms of mania and determine predictors of psychiatric hospitalizations during the 96 month follow-up. Eligible 6-12.9 year olds and their parents visiting 9 outpatient mental health clinics were invited to be screened with the Parent General Behavior Inventory 10-item Mania Scale. Of 605 children with elevated symptoms of mania eligible for follow-up, 538 (88.9%) had ≥ 1 of 16 possible follow-up interviews and are examined herein. Multivariate Cox regression indicated only four factors predicted hospitalizations: parental mental health problems (HR 1.80; 95% CI 1.21, 2.69); hospitalization prior to study entry (HR 3.03; 95% CI 1.80, 4.43); continuous outpatient mental health service use (HR 3.73; 95% CI 2.40, 5.50); and low parental assessment of how well treatment matched child's needs (HR 3.97; 95% CI 2.50, 6.31). Parental perspectives on mental health services should be gathered routinely, as they can signal treatment failures.

Longitudinal trajectories of mood symptoms and global functioning in youth at high risk for bipolar disorder

BACKGROUND

Little is known about the longitudinal course of mood symptoms and functioning in youth who are at high risk for bipolar disorder (BD). Identifying distinct course trajectories and predictors of those trajectories may help refine treatment approaches.

METHODS

This study examined the longitudinal course of mood symptoms and functioning ratings in 126 youth at high risk for BD based on family history and early mood symptoms. Participants were enrolled in a randomized trial of family-focused therapy and followed longitudinally (mean 2.0 years, SD = 53.6 weeks).

RESULTS

Using latent class growth analyses (LCGA), we observed three mood trajectories. All youth started the study with active mood symptoms. Following the index mood episode, participants were classified as having a "significantly improving course" (n = 41, 32.5% of sample), a "moderately symptomatic course" (n = 21, 16.7%), or a "predominantly symptomatic course" (n = 64, 50.8%) at follow-up. More severe depression, anxiety, and suicidality at the study's baseline were associated with a poorer course of illness. LCGA also revealed three trajectories of global functioning that closely corresponded to symptom trajectories; however, fewer youth exhibited functional recovery than exhibited symptomatic recovery.

LIMITATIONS

Mood trajectories were assessed within the context of a treatment trial. Ratings of mood and functioning were based on retrospective recall.

CONCLUSIONS

This study suggests considerable heterogeneity in the course trajectories of youth at high risk for BD, with a significant proportion (32.5%) showing long-term remission of symptoms. Treatments that enhance psychosocial functioning may be just as important as those that ameliorate symptoms in youth at risk for BD.

Pre-pubertal bipolar disorder: origins and current status of the controversy

BACKGROUND

Evidence from epidemiological, clinical and high-risk studies has established that the peak period of risk for onset of bipolar disorder spans late adolescence and early adulthood. However, the proposal of the existence of a pre-pubertal form of bipolar disorder manifesting in early childhood created substantial debate. In this narrative review, the literature and contributing factors pertaining to the controversy surrounding the proposed pre-pubertal bipolar disorder subtype are discussed. The resolution of the debate and lessons learned are highlighted.

MAIN BODY

In the mid 1990s US researchers proposed that chronic irritability and explosive temper in pre-pubertal children with pre-existing ADHD and/or other learning and developmental disorders might represent a variant of mania. A number of factors contributed to this proposal including severely ill children with no diagnostic home given changes in the ADHD DSM diagnostic criteria and over-reliance on symptoms and structured interviews rather than on a clinical assessment incorporating developmental history, social context and clinical course. Prospective studies of children at high familial risk did not support the proposed pre-pubertal bipolar phenotype; but rather provided convergent evidence that bipolar disorder onset in adolescence and early adulthood not uncommonly preceded by sleep and internalizing symptoms and most often debuting as depression in adolescence (after puberty). Epidemiological studies of population and hospital discharge data provided evidence that the pre-pubertal bipolar phenotype was largely a US driven phenomenon.

CONCLUSIONS

Psychiatric diagnosis is particularly challenging given the current lack of objective biomarkers. However, validity and utility of clinical diagnoses can be strengthened if all available predictive information is used to formulate a diagnosis. As in other areas of medicine, critical information required to make a valid diagnosis includes developmental history, clinical course, family history and treatment response-weighed against the known trajectories of classical disorders. Moreover, given that psychiatric disorders are in evolution over childhood and adolescence and symptoms, in of themselves, are often non-specific, a thorough clinical assessment incorporating collateral history and psychosocial context is paramount. Such an approach might have avoided or at least brought a more timely resolution to the debate on pre-pubertal mania.

Development of Three Web-Based Computerized Versions of the Kiddie Schedule for Affective Disorders and Schizophrenia Child Psychiatric Diagnostic Interview: Preliminary Validity Data

OBJECTIVE

To present initial validity data on three web-based computerized versions of the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-COMP).

METHOD

The sample for evaluating the validity of the clinician-administered KSADS-COMP included 511 youths 6-18 years of age who were participants in the Child Mind Institute Healthy Brain Network. The sample for evaluating the parent and youth self-administered versions of the KSADS-COMP included 158 youths 11-17 years of age recruited from three academic institutions.

RESULTS

Average administration time for completing the combined parent and youth clinician-administered KSADS-COMP was less time than previously reported for completing the paper-and-pencil K-SADS with only one informant (91.9 ± 50.1 minutes). Average administration times for the youth and parent self-administered KSADS-COMP were 50.9 ± 28.0 minutes and 63.2 ± 38.3 minutes, respectively, and youths and parents rated their experience using the web-based self-administered KSADS-COMP versions very positively. Diagnoses generated with all three KSADS-COMP versions demonstrated good convergent validity against established clinical rating scales and dimensional diagnostic-specific ratings derived from the KSADS-COMP. When parent and youth self-administered KSADS-COMP data were integrated, good to excellent concordance was also achieved between diagnoses derived using the self-administered and clinician-administered KSADS-COMP versions (area under the curve = 0.89-1.00).

CONCLUSION

The three versions of the KSADS-COMP demonstrate promising psychometric properties, while offering efficiency in administration and scoring. The clinician-administered KSADS-COMP shows utility not only for research, but also for implementation in clinical practice, with self-report preinterview ratings that streamline administration. The self-administered KSADS-COMP versions have numerous potential research and clinical applications, including in large-scale epidemiological studies, in schools, in emergency departments, and in telehealth to address the critical shortage of child and adolescent mental health specialists.

CLINICAL TRIAL REGISTRATION INFORMATION

Computerized Screening for Comorbidity in Adolescents With Substance or Psychiatric Disorders; https://clinicaltrials.gov/; NCT01866956.

Quantifying the Optimal Structure of the Autism Phenotype: A Comprehensive Comparison of Dimensional, Categorical, and Hybrid Models

OBJECTIVE

The two primary-seemingly contradictory-strategies for classifying child psychiatric syndromes are categorical and dimensional; conceptual ambiguities appear to be greatest for polythetic syndromes such as autism spectrum disorder (ASD). Recently, a compelling alternative has emerged that integrates both categorical and dimensional approaches (ie, a hybrid model), thanks to the increasing sophistication of analytic procedures. This study aimed to quantify the optimal phenotypic structure of ASD by comprehensively comparing categorical, dimensional, and hybrid models.

METHOD

The sample comprised 3,825 youth, who were consecutive referrals to a university developmental disabilities or child psychiatric outpatient clinic. Caregivers completed the Child and Adolescent Symptom Inventory-4R (CASI-4R), which includes an ASD symptom rating scale. A series of latent class analyses, exploratory and confirmatory factor analyses, and factor mixture analyses was conducted. Replication analyses were conducted in an independent sample (N = 2,503) of children referred for outpatient evaluation.

RESULTS

Based on comparison of 44 different models, results indicated that the ASD symptom phenotype is best conceptualized as multidimensional versus a categorical or categorical-dimensional hybrid construct. ASD symptoms were best characterized as falling along three dimensions (ie, social interaction, communication, and repetitive behavior) on the CASI-4R.

CONCLUSION

Findings reveal an optimal structure with which to characterize the ASD phenotype using a single, parent-report measure, supporting the presence of multiple correlated symptom dimensions that traverse formal diagnostic boundaries and quantify the heterogeneity of ASD. These findings inform understanding of how neurodevelopmental disorders can extend beyond discrete categories of development and represent continuously distributed traits across the range of human behaviors.

Baseline and follow-up activity and functional connectivity in reward neural circuitries in offspring at risk for bipolar disorder

Bipolar disorder (BD) is a serious psychiatric illness with demonstrated abnormalities in reward processing circuitry. Examining this circuitry in youth at familial risk for BD may provide further insight into the underlying mechanisms of BD development. In this study, we compared offspring of bipolar parents (OBP, n = 32), offspring of comparison parents with non-BD psychopathology (OCP, n = 36), and offspring of healthy parents (OHP, n = 39) during a functional magnetic resonance imaging reward processing task. Elastic net regression analyses identified 26 activity, functional connectivity (FC), and demographic variables that explained 34.24% of the variance in group (λ = 0.224). ANOVA and post-hoc analyses revealed that OBP had significantly lower right ventral striatum-left caudal anterior cingulate FC to loss (OBP versus OCP: p = 0.028, OBP versus OHP: p = 0.015) and greater right pars orbitalis-left (OBP versus OCP: p = 0.003, OBP versus OHP: p = 0.036) and -right (OBP versus OCP: p = 0.001, OBP versus OHP: p = 0.038) orbitofrontal cortex FC to reward versus OCP and OHP, respectively. These findings were not affected by non-BD psychopathology, psychotropic medication use, or symptomatology. There were no changes in, or relationships between, neuroimaging or symptom measures at follow-up (mean(SD) = 2.70(1.22) year inter-scan interval) in a subset of youth with follow-up data (OBP, n = 14; OCP, n = 8; OHP, n = 19). These findings suggest that lower right ventral striatum-left caudal anterior cingulate FC to loss and greater right pars orbitalis-orbitofrontal cortex FC to reward may be trait-level neural markers that may reflect risk for BD in at-risk youth. These findings comprise important steps toward identifying neural markers of BD risk, which may enhance early identification and guide interventions for youth at familial risk for BD.

White matter - emotion processing activity relationships in youth offspring of bipolar parents

BACKGROUND

Early detection of Bipolar Disorder (BD) is critical for targeting interventions to delay or prevent illness onset. Yet, the absence of objective BD biomarkers makes accurately identifying at-risk youth difficult. In this study, we examined how relationships between white matter tract (WMT) structure and activity in emotion processing neural circuitry differentiate youth at risk for BD from youth at risk for other psychiatric disorders.

METHODS

Offspring (ages 8-17) of parents with BD (OBP, n = 32), offspring of comparison parents with non-BD psychopathology (OCP, n = 30), and offspring of healthy parents (OHP, n = 24) underwent diffusion tensor and functional magnetic resonance imaging while performing an emotional face processing task. Penalized and multiple regression analyses included GROUP(OBP,OCP)xWMT interactions as main independent variables, and emotion processing activity as dependent variables, to determine significant group differences in WMT-activity relationships.

RESULTS

8 GROUPxWMT interaction variables contributed to 16.5% of the variance in amygdala and prefrontal cortical activity to happy faces. Of these, significant group differences in slopes (inverse for OBP, positive for OCP) existed for the relationship between forceps minor radial diffusivity and rostral anterior cingulate activity (p = 0.014). Slopes remained significantly different in unmedicated youth without psychiatric disorders (p = 0.017) and were moderated by affective lability symptoms (F(1,29) = 5.566, p = 0.036).

LIMITATIONS

Relatively small sample sizes were included.

CONCLUSIONS

Forceps minor radial diffusivity-rostral anterior cingulate activity relationships may reflect underlying neuropathological processes that contribute to affectively labile youth at risk for BD and may help differentiate them from youth at risk for other psychiatric disorders.

Factors Influencing Emerging Adults' Use of Outpatient Mental Health Services

Rates of treatment utilization decline as adolescents make the transition to adulthood even though young adults are particularly vulnerable to the negative outcomes of untreated mental illness. Although a variety of factors have been explored to explain decreased treatment utilization in this age group, previous research has almost exclusively employed cross-sectional methods rather than following a group of youth as they enter adulthood. The current study aims to address this methodological limitation by assessing treatment utilization in emerging adults who began participating in a longitudinal study during childhood. One hundred and thirty seven youth who turned 18 during the 96-month follow-up period were included in the current analyses. Demographic and socioeconomic variables such as sex, race, and insurance status and clinical variables such as psychiatric diagnoses and perceptions of treatment effectiveness were investigated as factors potentially associated with outpatient treatment use before and after age 18. Prior to age 18, youth reported using outpatient services at 75% of their visits, but after age 18, outpatient treatment utilization dropped to around 50%. White race, increased parental stress, and increased parental perception of treatment usefulness were associated with greater treatment use prior to age 18, whereas only increased youth perception of symptom-related dysfunction were associated with increased treatment use after age 18. Findings point to the importance of including youth preferences and perceptions of dysfunction in treatment decisions across adolescence in order to optimize treatment use following the transition to adulthood.

Association of Neuroimaging Measures of Emotion Processing and Regulation Neural Circuitries With Symptoms of Bipolar Disorder in Offspring at Risk for Bipolar Disorder

IMPORTANCE

Bipolar disorder (BD) is difficult to distinguish from other psychiatric disorders. Neuroimaging studies can identify objective markers of BD risk.

OBJECTIVE

To identify neuroimaging measures in emotion processing and regulation neural circuitries and their associations with symptoms specific to youth at risk for BD.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional (August 1, 2011, to July 31, 2017) and longitudinal (February 1, 2013, to November 30, 2017) neuroimaging study performed at the University of Pittsburgh Medical Center compared a sample of 31 offspring of parents with BD (OBP) with 28 offspring of comparison parents with non-BD psychopathologies (OCP) and 21 offspring of healthy parents (OHP); OBP, OCP, and OHP were recruited from the Bipolar Offspring Study and the Longitudinal Assessment of Manic Symptoms Study.

MAIN OUTCOMES AND MEASURES

Group differences in activity and functional connectivity during emotional face processing and n-back task performance in amygdala, dorsolateral and ventrolateral prefrontal cortices (PFC), caudal anterior cingulate cortices (cACC), and rostral anterior cingulate cortices (rACC) neuroimaging measures showing between-group differences and symptom severity (anxiety, affective lability, depression, mania). We hypothesized that elevated amygdala activity and/or lower PFC activity and abnormal amygdala to PFC functional connectivity would distinguish OBP from OCP and OHP, and magnitudes of these abnormalities would positively correlate with elevated symptom severity. We explored associations between changes in neuroimaging and symptom measures over follow-up (mean [SD], 2.9 [1.4] years) in a subset of participants (n = 30).

RESULTS

Eighty participants were included (mean [SD] age, 14.2 (2.1) years; 35 female). Twelve neuroimaging measures explained 51% of the variance in the results of neuroimaging measures overall. Of the 12, 9 showed significant main associations of the group; however, after post hoc analyses and Bonferroni corrections, only 7 showed statistically significant associations between groups (corrected P < .05 for all). Of the 7, 2 showed significant relationships with symptoms. Offspring of parents with BD had greater right rACC activity when regulating attention to happy faces vs OCP (mean [SD] difference, 0.744 [0.249]; 95% CI, 0.134-1.354; P = .01), which positively correlated with affective lability severity (ρ = 0.304; uncorrected P = .006). Offspring of parents with BD had greater amygdala to left cACC functional connectivity when regulating attention to fearful faces vs OCP (mean [SD] difference, 0.493 [0.169]; 95% CI, 0.079-0.908; P = .01). Increases in this measure positively correlated with increases in affective lability over follow-up (r = 0.541; P = .003).

CONCLUSIONS AND RELEVANCE

Greater anterior cingulate cortex activity and functional connectivity during emotion regulation tasks may be specific markers of BD risk. These findings highlight potential neural targets to aid earlier identification of and guide new treatment developments for BD.

Diagnostic efficiency of the CBCL thought problems and DSM-oriented psychotic symptoms scales for pediatric psychotic symptoms

We compared the diagnostic efficiency of the Child Behavior Checklist (CBCL) Thought Problems subscale and the rationally derived DSM-oriented psychotic symptoms scale (DOPSS) to identify clinically concerning psychosis in a multi-site sample of youths seeking outpatient mental health services (N = 694). We operationally defined clinically concerning psychosis as the presence of clinically significant hallucinations or delusions, assessed by the Schedule for Affective Disorders and Schizophrenia psychosis items. Both the Thought Problems and DOPSS scores showed significant areas under the curve (AUCs = 0.65 and 0.70, respectively), but the briefer DOPSS showed statistically significantly better diagnostic efficiency for any clinically concerning psychosis, but the difference was small enough that it would not be clinically meaningful. The optimal psychosis screening cut-off score (maximizing sensitivity and specificity) was 68.5+ [corresponding diagnostic likelihood ratio (DiLR) = 1.59] for the Thought Problems subscale and 1.67+ (DiLR = 1.97) for the DOPSS. Both the CBCL Thought Problems and DOPSS are clinically useful for identifying psychotic symptoms in children, and although the DOPSS showed statistically better discriminating power, the difference was small so we would not necessarily recommend the DOPSS over standard scoring.

Diffusion imaging markers of bipolar versus general psychopathology risk in youth at-risk

Bipolar disorder (BD) is highly heritable. Thus, studies in first-degree relatives of individuals with BD could lead to the discovery of objective risk markers of BD. Abnormalities in white matter structure reported in at-risk individuals could play an important role in the pathophysiology of BD. Due to the lack of studies with other at-risk offspring, however, it remains unclear whether such abnormalities reflect BD-specific or generic risk markers for future psychopathology. Using a tract-profile approach, we examined 18 major white matter tracts in 38 offspring of BD parents, 36 offspring of comparison parents with non-BD psychopathology (depression, attention-deficit/hyperactivity disorder), and 41 offspring of healthy parents. Both at-risk groups showed significantly lower fractional anisotropy (FA) in left-sided tracts (cingulum, inferior longitudinal fasciculus, forceps minor), and significantly greater FA in right-sided tracts (uncinate fasciculus and inferior longitudinal fasciculus), relative to offspring of healthy parents (P < 0.05). These abnormalities were present in both healthy and affected youth in at-risk groups. Only offspring (particularly healthy offspring) of BD parents showed lower FA in the right superior longitudinal fasciculus relative to healthy offspring of healthy parents (P < 0.05). We show, for the first time, important similarities, and some differences, in white matter structure between offspring of BD and offspring of non-BD parents. Findings suggest that lower left-sided and higher right-sided FA in tracts important for emotional regulation may represent markers of risk for general, rather than BD-specific, psychopathology. Lower FA in the right superior longitudinal fasciculus may protect against development of BD in offspring of BD parents.

The Behavioral Approach System (BAS) Model of Vulnerability to Bipolar Disorder: Evidence of a Continuum in BAS Sensitivity across Adolescence

Behavioral Approach System (BAS) sensitivity has been implicated in the development of a variety of different psychiatric disorders. Prominent among these in the empirical literature are bipolar spectrum disorders (BSDs). Given that adolescence represents a critical developmental stage of risk for the onset of BSDs, it is important to clarify the latent structure of BAS sensitivity in this period of development. A statistical approach especially well-suited for delineating the latent structure of BAS sensitivity is taxometric analysis, which is designed to evaluate whether the latent structure of a construct is taxonic (i.e., categorical) or dimensional (i.e., continuous) in nature. The current study applied three mathematically non-redundant taxometric procedures (i.e., MAMBAC, MAXEIG, and L-Mode) to a large community sample of adolescents (n = 12,494) who completed two separate measures of BAS sensitivity: the BIS/BAS Scales Carver and White (Journal of Personality and Social Psychology, 67, 319-333. 1994) and the Sensitivity to Reward and Sensitivity to Punishment Questionnaire (Torrubia et al. Personality and Individual Differences, 31, 837-862. 2001). Given the significant developmental changes in reward sensitivity that occur across adolescence, the current investigation aimed to provide a fine-grained evaluation of the data by performing taxometric analyses at an age-by-age level (14-19 years; n for each age ≥ 883). Results derived from taxometric procedures, across all ages tested, were highly consistent, providing strong evidence that BAS sensitivity is best conceptualized as dimensional in nature. Thus, the findings suggest that BAS-related vulnerability to BSDs exists along a continuum of severity, with no natural cut-point qualitatively differentiating high- and low-risk adolescents. Clinical and research implications for the assessment of BSD-related vulnerability are discussed.

Omega-3 supplementation associated with improved parent-rated executive function in youth with mood disorders: secondary analyses of the omega 3 and therapy (OATS) trials

BACKGROUND

Improvements in executive functioning (EF) may lead to improved quality of life and lessened functional impairment for children with mood disorders. The aim was to assess the impact of omega-3 supplementation (Ω3) and psychoeducational psychotherapy (PEP), each alone and in combination, on EF in youth with mood disorders. We completed secondary analyses of two randomized controlled trials (RCTs) of Ω3 and PEP for children with depression and bipolar disorder.

METHODS

Ninety-five youths with depression or bipolar disorder not otherwise specified/cyclothymic disorder were randomized in 12-week RCTs. Two capsules (Ω3 or placebo) were given twice daily (1.87 g Ω3 total daily, mostly eicosapentaenoic acid). Families randomized to PEP participated in twice-weekly 50-min sessions. Analyses assess impact of interventions on the Behavior Rating Inventory of Executive Functioning (BRIEF) parent-report Global Executive Composite (GEC) and two subscales, Behavior Regulation (BRI) and Metacognition (MI) Indices. Intent-to-treat repeated measures ANOVAs, using multiple imputation for missing data, included all 95 randomized participants. Trials were registered with www.clinicaltrials.gov, NCT01341925 & NCT01507753.

RESULTS

Participants receiving Ω3 (aggregating combined and monotherapy) improved significantly more than aggregated placebo on GEC (p = .001, d = .70), BRI (p = .004, d = .49), and MI (p = .04, d = .41). Ω3 alone (d = .49) and combined with PEP (d = .67) each surpassed placebo on GEC. Moderation by attention-deficit/hyperactivity disorder (ADHD) comorbidity was nonsignificant although those with ADHD showed nominally greater gains. PEP monotherapy had negligible effect.

CONCLUSIONS

Decreased impairment in EF was associated with Ω3 supplementation in youth with mood disorders. Research examining causal associations of Ω3, EF, and mood symptoms is warranted.

Symptom Dimensions and Trajectories of Functioning Among Bipolar Youth: A Cluster Analysis

BACKGROUND

Accurate assessment of pediatric bipolar disorder (BD) is important for allocating appropriate treatment, but it is complicated by significant heterogeneity in symptom presentation and high rates of comorbidity. Investigating clinical subtypes of the disorder may help to clarify diagnostic boundaries and inform targeted treatment. This study used a full diagnostic instrument to examine symptom patterns among youth with BD.

METHOD

Trained interviewers completed the Washington University Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) with 71 children (7 to 13 y of age) and families as part of the baseline assessment for a randomized clinical trial of Child- and Family-focused Cognitive-Behavioral Therapy (CFF-CBT) compared with treatment as usual (TAU) for pediatric BD. All participants met DSM-IV-TR criteria for a bipolar spectrum disorder. Hierarchical and K-means cluster analyses were performed. Resultant clusters were compared on symptom severity and psychosocial functioning at baseline and across treatment.

RESULTS

Two distinct symptom profiles emerged: "dysregulated/defiant" and "classic presentation." The dysregulated/defiant cluster was characterized by more externalizing and disruptive behaviors, whereas the classic cluster presented with more severe depression, hallmark manic symptoms, anxiety, and inattention. CFF-CBT consistently promoted psychosocial coping skills, such as problem solving and self-control, for the dysregulated/defiant cluster. TAU also promoted these skills among the individuals in the classic presentation group but not those with symptoms in the dysregulated/defiant cluster.

DISCUSSION

Pediatric BD may be characterized by distinct phenotypes with unique etiologies and pathways to impairment. The use of a parametric approach to classify the diverse symptom presentations helped yield valuable insights into how to promote the best prognosis for improved functional outcomes in CFF-CBT versus TAU for youth with pediatric BD.

Bipolar disorder in youth is associated with increased levels of vitamin D-binding protein

Genetic, dietary, and inflammatory factors contribute to the etiology of major mood disorders (MMD), thus impeding the identification of specific biomarkers to assist in diagnosis and treatment. We tested association of vitamin D and inflammatory markers in 36 adolescents with bipolar disorder (BD) and major depressive disorder (MDD) forms of MMD and without MMD (non-mood control). We also assessed the overall level of inflammation using a cell-based reporter assay for nuclear factor kappa-B (NFκB) activation and measuring antibodies to oxidized LDL. We found that these factors were similar between non-mood and MMD youth. To identify potential biomarkers, we developed a screening immunoprecipitation-sequencing approach based on inflammatory brain glia maturation factor beta (GMFβ). We discovered that a homolog of GMFβ in human plasma is vitamin D-binding protein (DBP) and validated this finding using immunoprecipitation with anti-DBP antibodies and mass spectrometry/sequencing analysis. We quantified DBP levels in participants by western blot. DBP levels in BD participants were significantly higher (136%) than in participants without MMD (100%). The increase in DBP levels in MDD participants (121.1%) was not statistically different from these groups. The DBP responds early to cellular damage by binding of structural proteins and activating inflammatory cells. A product of enzymatic cleavage of DBP has been described as macrophage-activating factor. Circulating DBP is comprised of heterogenous high and low molecular fractions that are only partially recognized by mono- and polyclonal ELISA and are not suitable for the quantitative comparison of DBP in non-mood and MDD participants. Our data suggest DBP as a marker candidate of BD warranting its validation in a larger cohort of adolescent and adult MMD patients.

Diagnostic Accuracy of the CASI-4R Psychosis Subscale for Children Evaluated in Pediatric Outpatient Clinics

Diagnostic accuracy of the Diagnostic and Statistical Manual of Mental Disorders-oriented Child and Adolescent Symptom Inventory (CASI-4R) Psychotic Symptoms scale was tested using receiver operating characteristic analyses to identify clinically significant psychotic symptoms. Participants were new outpatients (N = 700), ages 6.0 to 12.9 years (M = 9.7, SD = 1.8) at 9 child outpatient mental health clinics, who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) Study baseline assessment. Because LAMS undersampled participants with low mania scores by design, present analyses weighted low scorers to produce unbiased estimates. Psychotic symptoms, operationally defined as a score of 3 or more for hallucinations or 4 or more for delusions based on the Schedule for Affective Disorders and Schizophrenia (K-SADS) psychosis items, occurred in 7% of youth. K-SADS diagnoses for those identified with psychotic symptoms above threshold included major depressive disorder, bipolar spectrum disorder, attention deficit/hyperactivity disorder, posttraumatic stress disorder, psychotic disorders, and autism spectrum disorder. The optimal psychosis screening cut score (maximizing sensitivity and specificity) was 2.75+ (corresponding diagnostic likelihood ratio [DiLR] = 4.29) for the parent version and 3.50+ (DiLR = 5.67) for the teacher version. The Area under the Curve for parent and teacher report was .83 and .74 (both p < .001). Parent report performed significantly better than teacher report for identifying psychotic symptoms above threshold (p = .03). The CASI-4R Psychosis subscale (J) appears clinically useful for identifying psychotic symptoms in children because of its brevity and accuracy.

Using machine learning and surface reconstruction to accurately differentiate different trajectories of mood and energy dysregulation in youth

Difficulty regulating positive mood and energy is a feature that cuts across different pediatric psychiatric disorders. Yet, little is known regarding the neural mechanisms underlying different developmental trajectories of positive mood and energy regulation in youth. Recent studies indicate that machine learning techniques can help elucidate the role of neuroimaging measures in classifying individual subjects by specific symptom trajectory. Cortical thickness measures were extracted in sixty-eight anatomical regions covering the entire brain in 115 participants from the Longitudinal Assessment of Manic Symptoms (LAMS) study and 31 healthy comparison youth (12.5 y/o;-Male/Female = 15/16;-IQ = 104;-Right/Left handedness = 24/5). Using a combination of trajectories analyses, surface reconstruction, and machine learning techniques, the present study aims to identify the extent to which measures of cortical thickness can accurately distinguish youth with higher (n = 18) from those with lower (n = 34) trajectories of manic-like behaviors in a large sample of LAMS youth (n = 115; 13.6 y/o; M/F = 68/47, IQ = 100.1, R/L = 108/7). Machine learning analyses revealed that widespread cortical thickening in portions of the left dorsolateral prefrontal cortex, right inferior and middle temporal gyrus, bilateral precuneus, and bilateral paracentral gyri and cortical thinning in portions of the right dorsolateral prefrontal cortex, left ventrolateral prefrontal cortex, and right parahippocampal gyrus accurately differentiate (Area Under Curve = 0.89;p = 0.03) youth with different (higher vs lower) trajectories of positive mood and energy dysregulation over a period up to 5years, as measured by the Parent General Behavior Inventory-10 Item Mania Scale. Our findings suggest that specific patterns of cortical thickness may reflect transdiagnostic neural mechanisms associated with different temporal trajectories of positive mood and energy dysregulation in youth. This approach has potential to identify patterns of neural markers of future clinical course.

Longitudinal course and characteristics of cyclothymic disorder in youth

OBJECTIVES

Epidemiological studies suggest that cyclothymic disorder is the most prevalent subtype of bipolar disorder (BD). However, it is rarely diagnosed, especially in youth. This may be because it can be difficult to ascertain whether a youth meets diagnostic criteria. Clearer, easy-to-apply criteria could reduce misdiagnosis. The objective oftable this study was to determine whether proposed research diagnostic criteria for cyclothymic disorder (RDCyc), based on DSM-5 criteria, could be quantified and validated in youth.

METHODS

Participants from the Longitudinal Assessment of Manic Symptoms (LAMS) study were recruited based on symptoms of mania and followed prospectively. RDCyc criteria were: 1) At least one core symptom each of mania and depression; 2) one additional symptom of mania and of depression; 3) persistence over two consecutive six-month periods, and 4) impairment. Exclusionary criteria were having a [hypo]manic or depressive episode. Outcomes at the two-year follow-up were compared between RDCyc youth and other diagnostic groups (BD I/II, BD NOS/non-RDCyc cyclothymic disorder, disruptive behavior disorders [DBD], depression).

RESULTS

Thirty-seven youth met RDCyc criteria. There were no consistent differences between the RDCyc youth and youth with other BD subtypes (ps=0.001-0.960, with all-but-one p value >0.02). RDCyc youth had higher depression (p<0.0005) and mania scores (p=0.001), lower functioning (p=0.012), and higher suicide risk than DBD youth (p=0.001). They had higher mania scores than depressed youth (p.018).

LIMITATIONS

The majority of youth in the sample were recruited due to elevated symptoms of mania, which may limit the generalizability of the results. Youth were followed for two years, which may not be long enough to determine whether or not they will eventually develop a manic or depressive episode.

CONCLUSIONS

Applying RDCyc criteria identified youth who were similar to others with BD and were more impaired than those with DBD. Using these criteria could reduce misdiagnosis and increase our understanding of this prevalent, but largely ignored, diagnosis.

Reward-related neural activity and structure predict future substance use in dysregulated youth

BACKGROUND

Identifying youth who may engage in future substance use could facilitate early identification of substance use disorder vulnerability. We aimed to identify biomarkers that predicted future substance use in psychiatrically un-well youth.

METHOD

LASSO regression for variable selection was used to predict substance use 24.3 months after neuroimaging assessment in 73 behaviorally and emotionally dysregulated youth aged 13.9 (s.d. = 2.0) years, 30 female, from three clinical sites in the Longitudinal Assessment of Manic Symptoms (LAMS) study. Predictor variables included neural activity during a reward task, cortical thickness, and clinical and demographic variables.

RESULTS

Future substance use was associated with higher left middle prefrontal cortex activity, lower left ventral anterior insula activity, thicker caudal anterior cingulate cortex, higher depression and lower mania scores, not using antipsychotic medication, more parental stress, older age. This combination of variables explained 60.4% of the variance in future substance use, and accurately classified 83.6%.

CONCLUSIONS

These variables explained a large proportion of the variance, were useful classifiers of future substance use, and showed the value of combining multiple domains to provide a comprehensive understanding of substance use development. This may be a step toward identifying neural measures that can identify future substance use disorder risk, and act as targets for therapeutic interventions.

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

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

Diagnostic Efficiency of the Child and Adolescent Symptom Inventory (CASI-4R) Depression Subscale for Identifying Youth Mood Disorders

This study examined the diagnostic and clinical utility of the Child and Adolescent Symptom Inventory-4 R (CASI-4 R) Depressive and Dysthymia subscale for detecting mood disorders in youth (ages 6-12; M = 9.37) visiting outpatient mental health clinics. Secondary analyses (N = 700) utilized baseline data from the Longitudinal Assessment of Manic Symptoms study. Semistructured interviews with youth participants and their parents/caregivers determined psychiatric diagnoses. Caregivers and teachers completed the CASI-4 R. CASI-4 R depressive symptom severity and symptom count scores each predicted mood disorder diagnoses. Both caregiver scores (symptom severity and symptom count) of the CASI-4 R subscale significantly identified youth mood disorders (areas under the curve [AUCs] = .78-.79, ps < .001). The symptom severity version showed a small but significant advantage. Teacher symptom severity report did not significantly predict mood disorder diagnosis (AUC = .56, p > .05), whereas the teacher symptom count report corresponded to a small effect size (AUC = .61, p < .05). The CASI-4 R Depression scale showed strong incrememental validity even controlling for the other CASI-4 R scales. Caregiver subscale cutoff scores were calculated to assist in ruling in (diagnostic likelihood ratio [DLR] = 3.73) or ruling out (DLR = 0.18) presence of a mood disorder. The CASI-4 R Depressive subscale caregiver report can help identify youth mood disorders, and using DLRs may help improve diagnostic accuracy.

Parenting Stress Among Caregivers of Children With Bipolar Spectrum Disorders

Caregivers of psychiatrically impaired children experience considerable parenting stress. However, no research has evaluated parenting stress within the context of pediatric bipolar spectrum disorders (BPSD). Thus, the aim of this investigation was to identify predictors and moderators of stress among caregivers in the Longitudinal Assessment of Manic Symptoms study. Participants included 640 children and their caregivers in the Longitudinal Assessment of Manic Symptoms cohort. Children had a mean age of 9.4 ± 1.9 years (68% male, 23% BPSD); parents had a mean age of 36.5 ± 8.3 years (84% mothers). Children with BPSD had more service utilization, psychiatric diagnoses, mood and anxiety symptoms, and functional impairment but fewer disruptive behavior disorders. Caregivers of children with BPSD were more likely than caregivers of children without BPSD to have a partner, elevated depressive symptoms, antisocial tendencies, and parenting stress (Cohen's d = .49). For the whole sample, higher child IQ, mania, anxiety, disruptive behavior, and caregiver depression predicted increased parenting stress; maternal conduct disorder predicted lower stress. Child anxiety and disruptive behavior were associated with elevated caregiver stress only for non-BPSD children. Caregivers of children with BPSD experience significant burden and thus require specialized, family-focused interventions. As stress was also elevated, to a lesser degree, among depressed caregivers of children with higher IQ, mania, anxiety, and disruptive behavior, these families may need additional supports as well. Although parents with conduct/antisocial problems evidenced lower stress, these difficulties should be monitored. Thus, parenting stress should be evaluated and addressed in the treatment of childhood mental health problems, especially BPSD.

Development of Alcohol and Drug Use in Youth With Manic Symptoms

OBJECTIVE

This analysis examined alcohol and drug use over a 6-year follow-up of children in the Longitudinal Assessment of Manic Symptoms (LAMS) study.

METHOD

LAMS screened 6- to 12.9-year-old children visiting 9 child outpatient mental health (MH) clinics, using the Parent General Behavior Inventory 10-item mania scale. All children with scores ≥12 and a matched group with scores ≤12 were invited to enroll. Children were assessed every 6 months. Assessments included demographics, family, MH history, child diagnoses, child stress, and alcohol and drug use. Univariate, bivariate, and interval censored survival analyses were conducted.

RESULTS

Of those >9 years at baseline, 34.9% used alcohol at least once, with 11.9% regular users; 30.1% used drugs at least once, with 16.2% regular users. Predictors of any alcohol use were parental marital status, older age at study entry, a primary diagnosis of disruptive behavior disorders at baseline, and number of impactful child life events. Predictors of regular alcohol use included parental marital status, age, and sustained high mania symptoms over the first 24 months of follow-up. Predictors of any drug use were single parent, parental substance use, and stressful child life events. Predictors of regular drug use were parental marital status, stressful child life events, and a baseline disruptive behavior disorder diagnosis. Baseline medications decreased the risk of regular drug use.

CONCLUSION

Longitudinal data on youth with elevated manic symptoms suggest that comorbid disruptive behavior disorder, manic symptom burden, family environment, and stress are predictors of initiation and regular use of substances.

Amygdala-prefrontal cortical functional connectivity during implicit emotion processing differentiates youth with bipolar spectrum from youth with externalizing disorders

OBJECTIVE

Both bipolar spectrum disorders (BPSD) and attention deficit hyperactivity disorder (ADHD) present with emotion-regulation deficits, but require different clinical management. We examined how the neurobiological underpinnings of emotion regulation might differentiate youth with BPSD versus ADHD (and healthy controls, HCs), specifically assessing functional connectivity (FxC) of amygdala-prefrontal circuitry during an implicit emotion processing task.

METHODS

We scanned a subset of the Longitudinal Assessment of Manic Symptoms (LAMS) sample, a clinically recruited cohort with elevated behavioral and emotional dysregulation, and age/sex-ratio matched HCs. Our sample consisted of 22 youth with BPSD, 30 youth with ADHD/no BPSD, and 26 HCs. We used generalized psychophysiological interaction (gPPI) to calculate group differences to emerging emotional faces vs. morphing shapes in FxC between bilateral amygdala and ventral prefrontal cortex/anterior cingulate cortex.

RESULTS

FxC between amygdala and left ventrolateral prefrontal cortex (VLPFC) in response to emotions vs. shapes differed by group (p=.05): while BPSD showed positive FxC (emotions>shapes), HC and ADHD showed inverse FxC (emotions<shapes). A group x emotion interaction was found in amygdala-subgenual cingulate FxC (p=.025), explained by differences in FxC in response to negative emotions. While BPSD showed positive FxC, HC showed inverse FxC; ADHD were intermediate. Amygdala-subgenual FxC was also positively associated with depressive symptoms and stimulant medication.

LIMITATIONS

Co-morbidity and relatively small sample size.

CONCLUSIONS

Youth with BPSD showed abnormally positive FxC between amygdala and regions in the ventral prefrontal cortex during emotion processing. In particular, the amygdala-VLPFC finding was specific to BPSD, and not influenced by other diagnoses or medications.

Construction of longitudinal prediction targets using semisupervised learning

In establishing prognostic models, often aided by machine learning methods, much effort is concentrated in identifying good predictors. However, the same level of rigor is often absent in improving the outcome side of the models. In this study, we focus on this rather neglected aspect of model development. We are particularly interested in the use of longitudinal information as a way of improving the outcome side of prognostic models. This involves optimally characterizing individuals' outcome status, classifying them, and validating the formulated prediction targets. None of these tasks are straightforward, which may explain why longitudinal prediction targets are not commonly used in practice despite their compelling benefits. As a way of improving this situation, we explore the joint use of empirical model fitting, clinical insights, and cross-validation based on how well formulated targets are predicted by clinically relevant baseline characteristics (antecedent validators). The idea here is that all these methods are imperfect but can be used together to triangulate valid prediction targets. The proposed approach is illustrated using data from the longitudinal assessment of manic symptoms study.

Validation of the Seven Up Seven Down Inventory in bipolar offspring: screening and prediction of mood disorders. Findings from the Dutch Bipolar Offspring Study

OBJECTIVE

To validate the Seven Up Seven Down (7U7D), an abbreviated version of the General Behavior Inventory (GBI), as screener for mood disorders and test its ability to predict mood disorders over time in individuals at risk for bipolar disorder (BD).

METHODS

Bipolar offspring (n=108) were followed from adolescence into adulthood and assessed at baseline, 1-, 5- and 12 years follow-up (T1-T4 respectively). Offspring were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children--Present and Lifetime Version, Structured Clinical Interview for DSM-IV Axis I Disorders and the GBI.

RESULTS

Performance of the GBI and 7U7D was functionally similar for the depression (7D) scale, but variable for the mania (7U) scale. As screener for mood disorders (T4), the 7D showed fair diagnostic efficiency (area under the curve (AUC) 0.68, p<0.01, OR 1.53, 95% CI 1.15-2.03). The discriminative validity for BD and unipolar disorder was only close to significant (7D AUC 0.66, p=0.078; 7U AUC 0.67, p=0.067). In terms of prediction of mood disorder onset between T1 and T4, the 7D, but not the 7U, was associated with new onset (AUC 0.67, p<0.05; HR 1.14, 95% CI 1.07-1.23). The 7U7D did not achieve significant prediction of BD.

LIMITATIONS

Relative small sample size and limited generalizability.

CONCLUSIONS

Based on the current study, the 7U7D shows limited potential as screening instrument for mood disorders in bipolar offspring. The clinical utility of the 7U7D needs further exploration for use in clinical and research settings.

Preliminary investigation of the relationships between sleep duration, reward circuitry function, and mood dysregulation in youth offspring of parents with bipolar disorder

BACKGROUND

Altered reward circuitry function is observed in individuals with bipolar disorder (BD) and their unaffected offspring (OBP). While OBP are at elevated risk for BD, modifiable risk factors that may exacerbate neural vulnerabilities in OBP remain under-characterized. As sleep loss is strongly linked to mania in BD, this study tested associations between sleep duration, reward circuitry function, and mood dysregulation in OBP.

METHODS

Two groups of youth unaffected with BD (9-17yr) completed a number-guessing fMRI reward paradigm: 25 OBP and 21 age-sex-IQ-matched offspring of control parents with non-BD psychopathology (OCP), to differentiate risk for BD from risk for psychopathology more broadly. Regressions tested effects of group status, self-reported past-week sleep duration, and their interaction on neural activity and bilateral ventral striatum (VS) functional connectivity to win>control. Correlations with parent-reported mood dysregulation were assessed.

RESULTS

Group effects were observed for right posterior insula activity (OCP>OBP) and VS-left posterior insula connectivity (OBP>OCP). Group^⁎sleep duration interactions were observed for left dorsal anterior-mid-cingulate (daMCC) activity and VS-left anterior insula/ventrolateral prefrontal cortex (VLPFC) connectivity. Specifically, sleep duration and daMCC activity were positively related in OBP, but negatively related in OCP and sleep duration and VS-left anterior insula/VLPFC connectivity were negatively related in OBP, but positively in OCP. Additionally, increased VS-left posterior insula connectivity and VS-left anterior insula/VLPFC connectivity were associated with greater mood dysregulation in OBP only.

LIMITATIONS

Cross-sectional design and small sample size.

CONCLUSIONS

Altered reward-related VS-insula connectivity could represent a neural pathway underpinning mood dysregulation in OBP, and may be modulated by shortened sleep duration.

Targeted use of growth mixture modeling: a learning perspective

From the statistical learning perspective, this paper shows a new direction for the use of growth mixture modeling (GMM), a method of identifying latent subpopulations that manifest heterogeneous outcome trajectories. In the proposed approach, we utilize the benefits of the conventional use of GMM for the purpose of generating potential candidate models based on empirical model fitting, which can be viewed as unsupervised learning. We then evaluate candidate GMM models on the basis of a direct measure of success; how well the trajectory types are predicted by clinically and demographically relevant baseline features, which can be viewed as supervised learning. We examine the proposed approach focusing on a particular utility of latent trajectory classes, as outcomes that can be used as valid prediction targets in clinical prognostic models. Our approach is illustrated using data from the Longitudinal Assessment of Manic Symptoms study. Copyright © 2016 John Wiley & Sons, Ltd.

Evaluation of Bipolar Disorder in Children and Adolescents Referred to a Mood Service: Diagnostic Pathways and Manic Dimensions

OBJECTIVES

Few studies have examined pediatric mental health services for early-onset bipolar disorder (BD). The goal of this study was to describe diagnostic pathways and manic dimensions in BD among referred children and adolescents.

METHODS

Data were obtained from a review of the charts of 814 subjects, 2 to 17 years of age, with a complaint of mood disturbances who were referred between 2003 and 2012 to a university-based child and adolescent clinic that specializes in mood disorders. After screening, eligible participants (N=494) were systematically assessed and followed to determine diagnoses on the basis of criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision in accordance with the best-estimate approach. Manic symptoms were subjected to principal component analysis to investigate the dimensional bipolar profile of the sample.

RESULTS

Among the total help-seeking sample, approximately one third of the participants dropped out at intake and, after an average follow-up of 1.7 years, one third had been determined to meet criteria for BD and one third did not fulfill operational criteria for BD. The diagnostic status was changed in 35% of patients: approximately 10% were false positive (going from any bipolar diagnosis to a nonbipolar diagnosis) and approximately 25% were false negative (going from a nonbipolar diagnosis to any bipolar diagnosis). Most patients who converted to a bipolar diagnosis were initially labeled with major depressive disorder or attention-deficit/hyperactivity disorder and had a longer follow-up period. Relevant manic dimensions were elation, grandiosity, and disruption, which explained 41.4% of total variance.

CONCLUSIONS

Regular reappraisal and follow-up of children and adolescents with mood disturbances provides a window for detection of BD (eg, of core manic dimensions). A coordinated and hierarchical connection among pediatric mental health services with different degrees of specialization is recommended.

Predicting clinical outcome from reward circuitry function and white matter structure in behaviorally and emotionally dysregulated youth

Behavioral and emotional dysregulation in childhood may be understood as prodromal to adult psychopathology. Additionally, there is a critical need to identify biomarkers reflecting underlying neuropathological processes that predict clinical/behavioral outcomes in youth. We aimed to identify such biomarkers in youth with behavioral and emotional dysregulation in the Longitudinal Assessment of Manic Symptoms (LAMS) study. We examined neuroimaging measures of function and white matter in the whole brain using 80 youth aged 14.0 (s.d.=2.0) from three clinical sites. Linear regression using the LASSO (Least Absolute Shrinkage and Selection Operator) method for variable selection was used to predict severity of future behavioral and emotional dysregulation measured by the Parent General Behavior Inventory-10 Item Mania Scale (PGBI-10M)) at a mean of 14.2 months follow-up after neuroimaging assessment. Neuroimaging measures, together with near-scan PGBI-10M, a score of manic behaviors, depressive behaviors and sex, explained 28% of the variance in follow-up PGBI-10M. Neuroimaging measures alone, after accounting for other identified predictors, explained ~1/3 of the explained variance, in follow-up PGBI-10M. Specifically, greater bilateral cingulum length predicted lower PGBI-10M at follow-up. Greater functional connectivity in parietal-subcortical reward circuitry predicted greater PGBI-10M at follow-up. For the first time, data suggest that multimodal neuroimaging measures of underlying neuropathologic processes account for over a third of the explained variance in clinical outcome in a large sample of behaviorally and emotionally dysregulated youth. This may be an important first step toward identifying neurobiological measures with the potential to act as novel targets for early detection and future therapeutic interventions.

Diagnostic Efficiency of Caregiver Report on the SCARED for Identifying Youth Anxiety Disorders in Outpatient Settings

This study investigated the diagnostic and clinical utility of the parent-rated Screen for Child Anxiety Related Emotional Disorders (SCARED-P) for detecting youth anxiety disorders. Youth ages 6 to 12 years, 11 months were recruited from 9 outpatient mental health clinics (N = 707). Consensus diagnoses were based on semistructured interviews (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with youth and caregivers; 31% were diagnosed with at least one anxiety disorder. Caregivers completed the SCARED-P to describe youth anxiety levels. SCARED-P scores were not considered during the consensus diagnoses. Areas under the curve (AUCs) from receiver operating characteristic analyses and diagnostic likelihood ratios (DLRs) quantified performance of the SCARED-P total score and subscale scores (generalized anxiety disorder and separation anxiety disorder). SCARED-P total scores had variable efficiency (AUCs = .69-.88), and Generalized Anxiety Disorder and Separation Anxiety subscale scores were excellent (AUCs = .86-.89) for identifying specific anxiety disorders. Optimal subscale cutoff scores were computed to help rule in (DLRs = 2.7-5.4) or rule out (DLRs < 1.0) anxiety disorders among youth. Results suggest that the Generalized Anxiety Disorder and Separation Anxiety SCARED-P subscales accurately identify their respective matched diagnoses. DLRs may aid clinicians in screening for youth anxiety disorders and improve accuracy of diagnosis.

Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder

Greater understanding of cognitive function in children and adolescents with bipolar disorder (BD) is of critical importance to improve our ability to design targeted treatments to help with real-world impairment, including academic performance. We sought to evaluate cognitive performance among children with either BD type I, II, or "not otherwise specified" (NOS) participating in multi-site Course and Outcome of Bipolar Youth study compared to typically developing controls (TDC) without psychopathology. In particular, we sought to test the hypothesis that BD-I and BD-II youths with full threshold episodes of mania or hypomania would have cognitive deficits, including in reversal learning, vs. those BD-NOS participants with sub-threshold episodes and TDCs. N = 175 participants (BD-I = 81, BD-II = 11, BD-NOS = 28, TDC = 55) completed Cambridge Neuropsychological Automated Testing Battery (CANTAB) tasks. A priori analyses of the simple reversal stage of the CANTAB intra-/extra-dimensional shift task showed that aggregated BD-I/II participants required significantly more trials to complete the task than either BD-NOS participants with sub-syndromal manic/hypomanic symptoms or than TDCs. BD participants across sub-types had impairments in sustained attention and information processing for emotionally valenced words. Our results align with prior findings showing that BD-I/II youths with distinct episodes have specific alterations in reversal learning. More broadly, our study suggests that further work is necessary to see the interaction between neurocognitive performance and longitudinal illness course. Additional work is required to identify the neural underpinnings of these differences as targets for potential novel treatments, such as cognitive remediation.

Is There a Bipolar Prodrome Among Children and Adolescents?

Bipolar disorder in youth substantially impairs behavior, family, and social functioning and interferes with developmental course. There is increasing interest in defining a bipolar prodrome similar to that reported in early-onset psychosis that will allow for earlier intervention and reduction in overall morbidity and mortality. Several lines of research have addressed this important issue including studies of offspring of bipolar parents, high-risk cohorts, and longitudinal follow-up of subjects with major depressive disorder (MDD), ADHD, and bipolar spectrum disorder. The development and validation of bipolar prodrome rating scales also shows promise. Recent attempts to intervene at earlier stages of bipolar disorder have led to some positive outcomes. However, a controversy remains concerning the identification and management of the earliest symptoms. Further research is needed to fully validate a bipolar prodrome and to determine the optimal course of action at various stages of illness.

Disruptive Mood Dysregulation Disorder and Bipolar Disorder Not Otherwise Specified: Fraternal or Identical Twins?

OBJECTIVE

The purpose of this study was to examine similarities and differences between disruptive mood dysregulation disorder (DMDD) and bipolar disorder not otherwise specified (BP-NOS) in baseline sociodemographic and clinical characteristics and 36 month course of irritability in children 6-12.9 years of age.

METHODS

A total of 140 children with DMDD and 77 children with BP-NOS from the Longitudinal Assessment of Manic Symptoms cohort were assessed at baseline, then reassessed every 6 months for 36 months.

RESULTS

Groups were similar on most sociodemographic and baseline clinical variables other than most unfiltered (i.e., interviewer-rated regardless of occurrence during a mood episode) Young Mania Rating Scale (YMRS) and parent-reported General Behavior Inventory-10 Item Mania (PGBI-10M) items. Children with DMDD received lower scores on every item (including irritability) except impaired insight; differences were significant except for sexual interest and disruptive-aggressive behavior. Children with DMDD received lower scores on eight of 10 PGBI-10M items, the other two items rated irritability. Youth with DMDD were significantly less likely to have a biological parent with a bipolar diagnosis than were youth with BP-NOS. Children with DMDD were more likely to be male and older than children with BP-NOS, both small effect sizes, but had nearly double the rate of disruptive behavior disorders (large effect). Caregiver ratings of irritability based on the Child and Adolescent Symptom Inventory-4R (CASI-4R) were comparable at baseline; the DMDD group had a small but significantly steeper decline in scores over 36 months relative to the BP-NOS group (b = -0.24, SE = 0.12, 95% CI -0.48 to -0.0004). Trajectories for both groups were fairly stable, in the midrange of possible scores.

CONCLUSIONS

In a sample selected for elevated symptoms of mania, twice as many children were diagnosed with DMDD than with BP-NOS. Children with DMDD and BP-NOS are similar on most characteristics other than manic symptoms, per se, and parental history of bipolar disorder. Chronic irritability is common in both groups. Comprehensive evaluations are needed to diagnose appropriately. Clinicians should not assume that chronic irritability leads exclusively to a DMDD diagnosis.

Parents' Perceived Treatment Match and Treatment Retention Over 12 Months Among Youths in the LAMS Study

OBJECTIVE

The goal of these analyses was to describe the 12-month prevalence of mental health services retention for youths ages six to 12 years and identify predictors of treatment retention. Data were from the Longitudinal Assessment of Manic Symptoms study.

METHODS

In a longitudinal cohort study, 416 children and their parents completed measures of mental health services use and parents' perception of the services and participated in semistructured psychodiagnostic interviews during a baseline and 12-month assessment. Logistic regression analyses examined the effects on 12-month treatment retention of demographic and clinical variables and parents' perception of how well their children's treatment matched their needs.

RESULTS

Sixty-nine percent of youths (N=289) continued to use services at 12 months. After the analyses controlled for other demographic and clinical factors, white race (p<.001) and greater functional impairment (p=.024) were associated with treatment retention; greater perceived treatment match at baseline significantly predicted retention above and beyond the effects of sociodemographic and clinical variables (p=.001).

CONCLUSIONS

Parents' perceptions about appropriateness of treatment, white race, and functional impairment predicted 12-month treatment retention.

Ten-year updated meta-analysis of the clinical characteristics of pediatric mania and hypomania

OBJECTIVES

The phenomenology and diagnosis of pediatric bipolar disorder has been controversial. We aimed to update a 2005 meta analysis of the prevalence of manic symptoms in youth, in order to determine whether the picture of pediatric mania has changed as research on pediatric bipolar disorder has grown.

METHODS

We conducted literature reviews in PsycINFO and PubMed; studies with the prevalence of manic symptoms in youth were included. Two raters coded each study; kappa was 0.86-1.0.

RESULTS

Twenty studies were meta-analyzed (N = 2,226 youths). The most common symptoms across bipolar subtypes, using a random-effects model, were: increased energy 79%, irritability 77%, mood lability 76%, distractibility 74%, goal-directed activity 72%, euphoric/elated mood 64%, pressured speech 63%, hyperactive 62%, racing thoughts 61%, poor judgment 61%, grandiosity 57%, inappropriate laughter 57%, decreased need for sleep 56%, and flight of ideas 54%. Symptom rates were heterogeneous across samples; potential predictors were explored but no clear patterns were found.

CONCLUSIONS

Debate continues about the definitions of pediatric bipolar disorder; the results of this meta-analysis suggest that there is significant heterogeneity of symptom prevalence between studies, and that symptoms vary widely across individuals. Understanding the roots of this heterogeneity could broaden understanding of the complex clinical presentation of pediatric mania, and aid in diagnosis.

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.

Altered functioning of reward circuitry in youth offspring of parents with bipolar disorder

BACKGROUND

Offspring of parents with bipolar disorder (BD) (BO) are at higher risk of BD than offspring of parents with non-BD psychopathology (NBO), although both groups are at higher risk than offspring of psychiatrically healthy parents (HC) for other affective and psychiatric disorders. Abnormal functioning in reward circuitry has been demonstrated previously in individuals with BD. We aimed to determine whether activation and functional connectivity in this circuitry during risky decision-making differentiated BO, NBO and HC.

METHOD

BO (n = 29; mean age = 13.8 years; 14 female), NBO (n = 28; mean age = 13.9 years; 12 female) and HC (n = 23; mean age = 13.7 years; 11 female) were scanned while performing a number-guessing reward task. Of the participants, 11 BO and 12 NBO had current non-BD psychopathology; five BO and four NBO were taking psychotropic medications.

RESULTS

A 3 (group) × 2 (conditions: win-control/loss-control) analysis of variance revealed a main effect of group on right frontal pole activation: BO showed significantly greater activation than HC. There was a significant main effect of group on functional connectivity between the bilateral ventral striatum and the right ventrolateral prefrontal cortex (Z > 3.09, cluster-p < 0.05): BO showed significantly greater negative functional connectivity than other participants. These between-group differences remained after removing youth with psychiatric disorders and psychotropic medications from analyses.

CONCLUSIONS

This is the first study to demonstrate that reward circuitry activation and functional connectivity distinguish BO from NBO and HC. The fact that the pattern of findings remained when comparing healthy BO v. healthy NBO v. HC suggests that these neuroimaging measures may represent trait-level neurobiological markers conferring either risk for, or protection against, BD in youth.

Distinct relationships between social aptitude and dimensions of manic-like symptoms in youth

Difficulties with interpersonal relationships have been reported in children and adolescents with manic symptoms, even if they do not fulfil criteria for a manic episode. The role of social aptitude (SA) in youths with manic symptoms has never been examined in the general population. Moreover, no study has examined whether SA is differentially associated with dimensions of manic symptoms. We hypothesised that youth with predominantly undercontrol manic symptoms (characterised by irritability) would show lower levels of SA; conversely, youth with predominantly exuberant symptoms would show better than average social skills. Our sample comprised 5325 participants from the 2004 British Child and Adolescent Mental Health Survey (B-CAMHS04), mean age 10.3 years, SD = 3.3, 48 % girls. Manic symptoms were assessed with the Development and Wellbeing Assessment by interviewing parents and young people. Children and adolescents with manic symptoms had a lower SA score, compared to the general population by parent report, but not by self-report. SA score was higher in youths with predominantly exuberant manic symptoms compared to the general population; whereas the youths with predominantly undercontrol manic symptoms had lower SA scores by parent and self-report. Our results provide further evidence for the distinction between exuberant and undercontrol manic symptoms and highlight the need to focus on SA in future research.

Long-term Safety of Asenapine in Pediatric Patients Diagnosed With Bipolar I Disorder: A 50-Week Open-Label, Flexible-Dose Trial

BACKGROUND

Sublingually administered asenapine was approved in March 2015 by the United States Food and Drug Administration for patients aged 10-17 years with an acute manic or mixed episode associated with bipolar I disorder (BP-1). This is the first long-term safety and tolerability study of asenapine in this population.

METHODS

Following the 3-week randomized, double-blind, placebo-controlled trial of patients aged 10-17 years with an acute manic or mixed episode associated with BP-1, patients could enroll in this flexible-dose (2.5-10 mg twice daily) open-label extension (OLE) study for an additional 50 weeks, conducted from August 2011 to September 2014 in the United States and Russia. Treatment-emergent adverse events (TEAEs) were assessed and predefined TEAEs of interest reported in addition to metabolic and anthropometric parameters. The Young Mania Rating Scale (YMRS) and Clinical Global Impressions scale in bipolar illness (CGI-BP) were used to assess effectiveness.

RESULTS

A total of 321 patients (lead-in study treatment: placebo, n = 80; asenapine, n = 241) were included; 267 (83.2 %) reported one or more TEAE and 181 (56.4 %) discontinued early, 48 (15.0 %) due to TEAEs. Of the predefined TEAEs of interest, combined somnolence/sedation/hypersomnia occurred most frequently (42.4 %) followed by oral hypoesthesia/dysgeusia (7.5 %). In total, 109 (34.8 %) patients experienced clinically significant weight gain (≥7 % increase). No clinically meaningful changes were noted for laboratory parameters measured. Eighteen patients met the criteria for new-onset metabolic syndrome (MBS) post-baseline during the extension study, whereas 10 patients who met MBS criteria at baseline did not meet MBS criteria at endpoint. A total of 12 patients met MBS at baseline and endpoint. Mean change in YMRS total score from OLE baseline was -9.2 points at week 50, and change in CGI-BP severity overall score was similar among all treatment groups (those who initially received asenapine and those who initially received placebo). After 26 weeks of treatment in the OLE, 79.2 % of patients were classified as YMRS 50 % responders relative to acute trial baseline.

CONCLUSIONS

Asenapine was generally well tolerated in pediatric patients with BP-1 during ≤50 weeks of open-label treatment; among predefined TEAEs of interest, the combination of somnolence/sedation/hypersomnia was the most common. Trial registration ClinicalTrials.gov: NCT01349907.

A Randomized Controlled Trial of Individual Family Psychoeducational Psychotherapy and Omega-3 Fatty Acids in Youth with Subsyndromal Bipolar Disorder

OBJECTIVE

This pilot study evaluates efficacy of omega-3 fatty acid supplementation (Ω3), individual family psychoeducational psychotherapy (IF-PEP), and their combination in youth with subsyndromal bipolar disorders (bipolar disorder not otherwise specified [BP-NOS], cyclothymic disorder [CYC]).

METHODS

This study was a 12 week, randomized trial of Ω3 versus placebo and IF-PEP versus active monitoring (AM) using a 2 × 2 design (Ω3 + PEP: n = 5; Ω3 + AM: n = 5; placebo + PEP: n = 7; placebo + AM: n = 6). Twenty-three youth ages 7-14 with BP-NOS or CYC were recruited via community advertisements and clinician referrals. Participants could be taking stable medication for attention-deficit/hyperactivity disorder and sleep aids, but no other psychotropics. Independent evaluators assessed participants at screen, baseline, and 2, 4, 6, 9, and 12 weeks. Primary outcome measures were the Kiddie Schedule for Affective Disorders (K-SADS) Depression (KDRS) and Mania (KMRS) Rating Scales, Children's Depression Rating Scale-Revised (CDRS-R), and Young Mania Rating Scale (YMRS). Ω3/placebo conditions were double-blind; independent evaluators were blind to psychotherapy condition.

RESULTS

Most participants (83%) completed the 12 week trial. Side effects were uncommon and mild. Intent-to-treat analyses indicated significant improvement in depressive symptoms (KDRS) for combined treatment relative to placebo and AM (p = 0.01, d = 1.70). Across groups, manic symptoms improved over time without significant treatment effects. Effect of IF-PEP on child depression compared with AM was medium (d = 0.63, CDRS-R) to large (d = 1.24, KDRS). Effect of Ω3 on depression was medium (d = 0.48, KDRS).

CONCLUSION

IF-PEP and Ω3 are well tolerated and associated with improved mood symptoms among youth with BP-NOS and CYC. Clinicaltrials.gov Identifier: NCT01507753.

Omega-3 Supplementation for Psychotic Mania and Comorbid Anxiety in Children

OBJECTIVES

Therapeutic benefits of omega-3 fatty acids (Ω3) for mood disorders, psychosis, and anxiety have been reported in the literature. The purpose of the present article is to provide a literature review of Ω3 supplementation for affective disorders and to illustrate the benefits of Ω3 with a case presentation of a young girl with a history of bipolar disorder-type 1 with psychotic features and generalized anxiety disorder.

METHODS

Reviewed literature includes treatment studies of the impact of Ω3 on child mood disorders supplemented by review of meta-analyses within the adult mood disorders literature. The subject of this case report participated in 11 in-depth diagnostic and functional assessments over 5 years as part of an unrelated study. Three years were presupplementation and 2 years were with supplementation with no other medication changes, thus making a naturalistic multiple-baseline single-subject experiment.

RESULTS

Augmentation over a 2 year period was notable for clinically significant and sustained improvement in depressive, manic, and psychotic symptoms.

CONCLUSION

Ω3 supplementation may be a safe, adjunct intervention for treating bipolar disorder in children and adolescents, even in the presence of psychotic and anxious features. The 2 year follow-up in this case offers hope of an accumulating and enduring benefit. Further research into mechanisms of Ω3 action and of combination treatment with other well-known interventions for mood disorders would be beneficial.