Clinical features of children with both ADHD and mania: does ascertainment source make a difference?

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

The dopamine transporter role in psychiatric phenotypes

The dopamine transporter (DAT) is one of the most relevant and investigated neurotransmitter transporters. DAT is a plasma membrane protein which plays a homeostatic role, controlling both extracellular and intracellular concentrations of dopamine (DA). Since unbalanced DA levels are known to be involved in numerous mental disorders, a wealth of investigations has provided valuable insights concerning DAT role into normal brain functioning and pathological processes. Briefly, this extensive but non-systematic review discusses what is recently known about the role of SLC6A3 gene which encodes the dopamine transporter in psychiatric phenotypes. DAT protein, SLC6A3 gene, animal models, neuropsychology, and neuroimaging investigations are also concisely discussed. To conclude, current challenges are reviewed in order to provide perspectives for future studies.

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

BACKGROUND

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Early risk factors for adult bipolar disorder in adolescents with mood disorders: a 15-year follow-up of a community sample

BACKGROUND

We aimed to outline the early risk factors for adult bipolar disorder (BPD) in adolescents with mood disorders.

METHODS

Adolescents (16-17 years old) with mood disorders (n = 287; 90 participants with hypomania spectrum episodes and 197 with major depressive disorder [MDD]) were identified from a community sample. Fifteen years later (at 30-33 years of age), mood episodes were assessed (n = 194). The risk of developing BPD (n = 22), compared with MDD (n = 104) or no mood episodes in adulthood (n = 68), was estimated via logistic regression. Adolescent mood symptoms, non-mood disorders, and family characteristics were assessed as potential risk factors.

RESULTS

Among the adolescents with mood disorders, a family history of BPD was the strongest predictor of developing BPD compared with having no mood episodes in adulthood (OR = 5.94; 95% CI = 1.11-31.73), whereas disruptive disorders significantly increased the risk of developing BPD compared with developing MDD (OR = 2.94; CI = 1.06-8.12). The risk that adolescents with MDD would develop adult BPD, versus having no mood episodes in adulthood, was elevated among those with an early disruptive disorder (OR = 3.62; CI = 1.09-12.07) or multiple somatic symptoms (OR = 6.60; CI = 1.70-25.67). Only disruptive disorders significantly predicted adult BPD among adolescents with MDD versus continued MDD in adulthood (OR = 3.59; CI = 1.17-10.97). Only a few adolescents with hypomania spectrum episodes continued to have BPD as adults, and anxiety disorders appeared to increase this risk.

CONCLUSIONS

Although most of the identified potential risk factors are likely general predictors of continued mood disorders, disruptive disorders emerged as specific predictors of developing adult BPD among adolescents with MDD.

Association of dopamine transporter gene variants with childhood ADHD features in bipolar disorder

Bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) exhibit remarkably high rates of comorbidity, as well as patterns of familial co-segregation. Epidemiological data suggests that these disorders either share a common genetic architecture or that ADHD features in BD may represent an etiologically distinct subtype. We previously used the Wender Utah Rating Scale (WURS) to assess ADHD features in BD families and identified three heritable factors relating to impulsivity, mood instability, and inattention. Linkage analysis revealed a LOD score of 1.33 for the inattention factor on 5p15.3 near the dopamine transporter gene (DAT1), which has been associated with both BD and ADHD. Pharmacological evidence also suggests a role for DAT in both disorders. We have now evaluated the association of ten DAT1 variants for the WURS total score and factors in an overlapping sample of 87 BD families. Significant associations for three SNPs were observed across the WURS measures, notably for a SNP in intron 8 with the WURS total score (P = 0.007) and for variants in introns 9 and 13 with mood instability (P = 0.009 and 0.004, respectively). Analysis of an independent sample of 52 BD cases and 46 healthy controls further supported association of the intron 8 variant with mood instability (P = 0.005), and a combined analysis confirmed the associations of this SNP with WURS total score. Impulsivity and mood instability (P = 0.002, 0.007, and 8 × 10(-4), respectively). These data suggest that variants within DAT1 may predispose to a subtype of BD characterized by early prodromal features that include attentional deficits.

Psychiatric comorbidity distribution and diversities in children and adolescents with attention deficit/hyperactivity disorder: a study from Turkey

OBJECTIVE

We aimed to determine distribution and diversities of psychiatric comorbidities in children and adolescents with attention deficit/hyperactivity disorder (ADHD) in terms of age groups, sex, and ADHD subtype.

MATERIALS AND METHODS

The sample included 6-18 year old children and adolescents from Turkey (N=108; 83 boys, 25 girls) diagnosed with ADHD. All comorbid diagnoses were determined based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version assessment.

RESULTS

96.3% of the cases were found to have at least one psychiatric comorbid diagnosis. The most frequent psychiatric comorbid disorder was oppositional defiant disorder (69.4%) followed by anxiety disorders (49%) and elimination disorders (27.8%). Disruptive behavior disorders were more common in ADHD-combined type. Depression and anxiety disorders were more common in girls. Separation anxiety disorder and elimination disorder were more common in children, whereas depression, bipolar disorder, obsessive-compulsive disorder, and social phobia were more common in the adolescents.

CONCLUSION

According to our results, when a diagnostic tool was used to assess the presence of comorbid psychiatric disorders in children and adolescents diagnosed with ADHD, almost all cases had at least one comorbid diagnosis. Therefore, especially in the clinical sample, ADHD cases should not be solely interpreted with ADHD symptom domains, instead they should be investigated properly in terms of accompanying psychiatric disorders.

Bipolar disorder co-morbidity in children with attention deficit hyperactivity disorder

The present study aimed at: (1) exploring rate and clinical features of superimposed bipolar disorder (BD) in Italian children with attention deficit hyperactivity disorder (ADHD), compared with a community sample, matched for age and gender; (2) exploring predictors of BD in ADHD children, by comparing ADHD children with or without superimposed BD. We studied 173 consecutive drug-naïve outpatients with ADHD (156 males and 17 females, mean age of 9.2 ± 2.3years, age range 6-17.5 years), diagnosed with a clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL)); the control group consisted of a community-based sample of 100 healthy children. The rate of children with a diagnosis of BD was higher in the ADHD group (29/173, 16.7%) compared with controls (1/100, 1%), (P<0.001). Among the 29 children with ADHD+BD, 16 (55.2%) had a Bipolar Disorder-Not Otherwise Specified (BD-NOS), and 11 (37.9%) showed ultrarapid cycling. Compared with children with ADHD without BD, they showed a higher rate of combined sub-type (21/29, 72.4%), a higher score at ADHD-Rating Scale (total score and hyperactivity subscale), higher rates of major depression, oppositional defiant disorder and conduct disorder. In summary, children with ADHD present a higher risk for developing a superimposed BD. The identification of clinical features with an increased risk of BD can improve diagnosis, prognosis and treatments.

[Pharmacotherapy in bipolar disorders during childhood and adolescence]

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Evidence for disruption in prefrontal cortical functions in juvenile bipolar disorder

OBJECTIVES

Systematic parsing of executive function processes is critical for the development of more specific models of neurobiological processes mediating disturbed cognition in youth with bipolar disorder (BPD).

METHODS

A sample of 33 children and adolescents with bipolar I disorder (BPD I) (mean age 12.1 +/- 3.0 years, 39% female) and 44 demographically matched healthy participants (mean age 12.9 +/- 2.8 years, 50% female) completed a neurocognitive battery including measures aimed at detection of disruption in prefrontal cortical circuitry (i.e., working memory, set shifting, and rule attainment).

RESULTS

Compared to healthy controls, BPD I children exhibited significant deficits in spatial working memory, visual sequencing and scanning, verbal fluency and abstract problem solving, particularly when a memory component was involved. In our spatial delayed response task, memory set size was parametrically varied; the performance pattern in BPD I children suggested deficits in short-term memory encoding and/or storage, rather than capacity limitations in spatial working memory. Earlier age at onset of illness and antipsychotic medication usage were associated with poorer performance on speeded information-processing tasks; however, severity of mood symptomatology and comorbidity with disruptive behavior disorders were not associated with task performance.

CONCLUSIONS

These results suggest impairment in measures of prefrontal cortical function in juvenile BPD I that are similar to those seen in the adult form of the illness, and implicate both the ventral and dorsolateral prefrontal cortex as loci of pathology in juvenile BPD. As these deficits were not associated with clinical state or comorbidity with other disorders, they may reflect trait-related impairments, a hypothesis that will be pursued further in longitudinal studies.

Differentiating bipolar disorder in Turkish prepubertal children with attention-deficit hyperactivity disorder

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) in children are frequently comorbid conditions. Because the coexistence of ADHD and mania seriously complicates the course of the condition and the treatment of children, diagnosing or missing this comorbidity has important clinical implications. There are very few systematic studies on the subject in the literature and BPD in children is not recognized or studied in most countries other than the USA. We aimed to differentiate Turkish prepubertal children with ADHD from those with comorbid ADHD and BPD and compare their clinical characteristics.

METHODS

A total of 147 treatment- and drug-naïve children, aged 7 to 13 years, who had been consecutively referred to the ADHD clinic, were evaluated using the Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime version (K-SADS-PL). Parents completed the Child Behavior Checklist (CBCL) 4-18 and the Parent-Young Mania Rating Scale (P-YMRS) prior to the clinical interview.

RESULTS

Twelve children (8.2%) had comorbid bipolar disorder (ADHD + BPD). The ADHD + BPD group had significantly higher rates of depressive disorders, oppositional defiant disorder, panic disorder and a family history of bipolar disorder compared with the ADHD group. The ADHD + BPD group had significantly more problems on the CBCL scale (anxiety/depression, social problems, thought problems, aggression, externalization, and total score) and on the P-YMRS (all items except for insight) compared with the ADHD group.

CONCLUSIONS

We conclude that ADHD + BPD in Turkish children represents a clinical picture different to that of ADHD alone, in which the clinical characteristics resemble those of children reported in the literature. Further long-term follow-up studies are needed in larger clinical and community samples.

Phenomenology and diagnosis of bipolar disorder in children, adolescents, and adults: complexities and developmental issues

This review addresses the phenomenology of mania/bipolar disorder from a developmental psychopathology perspective and uses cases with longitudinal information to illustrate major points. Beginning with a summary of the phenomenology of bipolar illness as it occurs in adults, the authors identify diagnostic complexities unique to children and adolescents. These include the challenges of characterizing elation and grandiosity; differentiating mania from comorbid symptoms, rages, sequelae of maltreatment, and typical developmental phenomena; and the unique manifestations of psychosis. We conclude with the observation that a significant difference between early and later onset bipolar disorder is that, in the former, there appears to be a global delay or arrest in the development of appropriate affect regulation; whereas in adult-onset bipolar illness, emotion dysregulation generally presents as an intermittent phenomenon. At this juncture, the study of childhood bipolar illness would benefit from a developmental psychopathology perspective to move beyond the level of cross-sectional symptom description to begin to study individuals over time, focusing on developmental, environmental, genetic, and neurobiological influences on manifest behavior.

Co-occurrence of bipolar and attention-deficit hyperactivity disorders in children

OBJECTIVES

Pediatric bipolar disorder (BPD) and attention-deficit hyperactivity disorder (ADHD) co-occur more frequently than expected by chance. In this review, we examine 4 potential explanations for the high rate of this common co-occurrence: (i) BPD symptom expression leads to overdiagnosis of ADHD in BPD youth; (ii) ADHD is a prodromal or early manifestation of pediatric-onset BPD; (iii) ADHD and associated factors (e.g., psychostimulants) lead to the onset of pediatric BPD; and (iv) ADHD and BPD share an underlying biological etiology (i.e., a common familial or genetic risk or underlying neurophysiology).

METHODS

Peer-reviewed publications of studies of children and adolescents with comorbid BPD and ADHD were reviewed.

RESULTS

There is a bidirectional overlap between BPD and ADHD in youth, with high rates of ADHD present in children with BPD (up to 85%), and elevated rates of BPD in children with ADHD (up to 22%). Phenomenologic, genetic, family, neuroimaging, and treatment studies revealed that BPD and ADHD have both common and distinct characteristics. While there are data to support all 4 explanations postulated in this paper, the literature most strongly suggests that ADHD symptoms represent a prodromal or early manifestation of pediatric-onset BPD in certain at-risk individuals. Bipolar disorder with comorbid ADHD may thus represent a developmentally specific phenotype of early-onset BPD.

CONCLUSIONS

The etiology of comorbid BPD and ADHD is likely multifactorial. Additional longitudinal and biological studies are warranted to clarify the relationships between BPD and ADHD since they may have important diagnostic and treatment implications.

An investigation of prepulse inhibition in pediatric bipolar disorder

OBJECTIVES

Deficits in prepulse inhibition (PPI), a measure of sensorimotor gating, have been noted in psychopathologies including schizophrenia and adult bipolar disorder (BPD). Sensorimotor gating deficits may contribute to the emotional and behavioral dysregulation characteristic of pediatric BPD. The current study investigated possible PPI deficits in children with BPD.

METHODS

Sixteen children with BPD (medicated, euthymic and non-psychotic) were compared with 13 control subjects on the magnitude of startle habituation, startle-alone response, and inhibition of startle following a 60 or 120-ms prepulse.

RESULTS

Both groups displayed startle inhibition by a prepulse, with no significant between-group differences on the magnitude of inhibition after the 60- or 120-ms prepulse. In addition, there were no between-group differences on habituation or baseline startle response. PPI level was not significantly correlated with mood symptoms and did not differ based on comorbid attention deficit hyperactivity disorder.

CONCLUSIONS

A lack of PPI deficits in our pediatric bipolar sample contrasts with previous results in adult bipolar and schizophrenic samples. These negative results may reflect the fact that our sample was medicated and was neither acutely manic nor psychotic. Deficits in sensorimotor gating may not be implicated in the emotional and behavioral dysregulation in pediatric BPD.

Practical Clues to Early Recognition of Bipolar Disorder: A Primary Care Approach

Early treatment can favorably impact the course of bipolar disorder, a lifelong illness. Because bipolar disorder can masquerade as various mental and physical illnesses-primarily major depressive disorder-patients with this condition frequently go unrecognized for years. During this recognition lag, such patients may present to their primary care physician on multiple occasions. Accordingly, primary care physicians would benefit from knowing the "clues" to early recognition of the disorder, because early recognition and management can reduce disability, improve social and employment stability, and result in improved functional outcomes. This review describes 3 pathways to the diagnosis of bipolar disorder relevant to the primary care setting: detection of mania or hypomania, differential diagnosis of recurrent depressive episodes, and identification of interepisode disorder and its comorbidities. We summarize these pathways in terms of a practical tool that a primary care physician can use to trigger further evaluation or referral.

A prospective follow-up study of pediatric bipolar disorder in boys with attention-deficit/hyperactivity disorder

OBJECTIVE

To examine patterns of persistence and remission in pediatric bipolar disorder attending to syndromatic, symptomatic, functional and affective definitions of remission of bipolar symptomatology in a longitudinal sample of ADHD children with comorbid bipolar disorder.

METHODS

ADHD boys (128) were followed over 1- and 4-year follow-up assessments with structured diagnostic interviews to assess the persistence of psychiatric comorbidity. The course and duration of bipolar disorder was estimated by calculating the time from age at onset and the age at remission reported at either the 1- or 4-year follow-up assessments.

RESULTS

Twenty-two (17%, Prevalent Cases) subjects met criteria for bipolar disorder at the baseline assessment. The average age of these subjects was 10.5+/-3.0 (range: 6 to 17 years) at baseline and 14.4+/-3.1 years of age at follow-up. The rate of remission was heavily dependent on the definition used. The rate of functional remission was the lowest and the rate of syndromatic remission was the highest. Regardless of the definition used, however, the disorder was chronic and lasted many years.

LIMITATIONS

These data should be considered preliminary due to the sample size and the absence of mood symptom rating scales.

CONCLUSIONS

That less than 20% of subjects attained functional remission or euthymia over the entire time period evaluated provides further evidence that pediatric bipolar disorder is a chronic mood disorder with a poor prognosis.

Employing parent, teacher, and youth self-report checklists in identifying pediatric bipolar spectrum disorders: an examination of diagnostic accuracy and clinical utility

The diagnosis of bipolar spectrum disorders (BPSD) is difficult to evaluate in child and adolescent populations. The current study examines whether commonly used behavior checklists- the Child Behavior Checklist, Teacher Report Form, and the Youth Self-Report form-are clinically useful in making a differential diagnosis between BPSD and other disorders. This study is the first to investigate the validity of integrating pairs of informants using these instruments to differentiate individuals with BPSD from those with disruptive behavior disorders, major depressive disorder, and any child or adolescent not meeting criteria for BPSD. Parent report best predicted diagnostic status, yet diagnostic efficiency statistics associated with these checklists were relatively poor. Results indicate that the Child Behavior Checklist has limited utility when attempting to derive clinically meaningful information about the presentation of juvenile BPSD.

Is there progression from irritability/dyscontrol to major depressive and manic symptoms? A retrospective community survey of parents of bipolar children

BACKGROUND

Although previous studies have discussed age-related changes in the presentation of early onset bipolar illness, the developmental progression of early symptoms remains unclear. The current study sought to trace parents' retrospective report of yearly occurrence of symptoms in a sample of children with and without a diagnosis of bipolar disorder in the community.

METHODS

Parents retrospectively rated the occurrence of 37 activated and withdrawn symptoms causing dysfunction for each year of their child's life (mean age 12.6 +/- 6.9). Children were divided into three groups based on parent report of diagnosis by a community clinician: bipolar (n=78); non-bipolar diagnosis (n=38); and well (no psychiatric diagnosis) (n=82). Principal components analysis was performed to understand the relationship among the symptom variables and their potential differences among the three groups as a function of age.

RESULTS

Four symptom components were derived and these began to distinguish children with bipolar disorder from the other groups at different ages. Component II (irritability/dyscontrol), which included temper tantrums, poor frustration tolerance, impulsivity, increased aggression, decreased attention span, hyperactivity and irritability, began to distinguish bipolar children from the others the earliest (i.e., from ages 1 to 6). The other components (I, III, and IV) which included symptoms more typical of adult depression (I), mania (III), and psychosis (IV), distinguished the children with a bipolar diagnosis from the others much later (between ages 7 and 12).

LIMITATIONS

The data were derived from retrospective reports by parents of their children's symptoms on a yearly symptom check list instrument which has not been previously utilized. Parents' ratings were not validated by an outside rater. Moreover, the children were diagnosed in the community and a formal diagnostic interview was not given.

CONCLUSIONS

By parental report, the cluster of symptoms in the irritability/dyscontrol component may characterize the earliest precursors to an illness eventually associated with more classic manic and depressive components that are diagnosed and treated as bipolar disorder in the community. These retrospective survey data suggesting a longitudinal evolution of symptom clusters in childhood bipolar-like illness identify a number of areas for prospective research and validation.

A preliminary meta-analysis of the child behavior checklist in pediatric bipolar disorder

BACKGROUND

A possible explanation for the ongoing controversy surrounding pediatric bipolar disorder is that differences in assessment methodologies lead to conflicting results. One way to address methodological differences in assessment across studies is to use a single standardized assessment of psychopathology to calibrate the findings reported in different studies. To this end, we conducted a meta-analysis of several studies that have employed the Child Behavior Checklist in the assessment of children with a diagnosis of bipolar disorder.

METHODS

MEDLINE was searched for all publications that utilized the Child Behavior Checklist in addition to structured diagnostic interviews to assess pediatric bipolar disorder. Random effects models were used to calculate combined estimates of Child Behavior Checklist clinical subscales.

RESULTS

Children with bipolar disorder had scaled scores of >70 in the Aggression, Attention Problems, and Anxious/Depressed subscales of the Child Behavior Checklist. The Child Behavior Checklist was useful in distinguishing bipolar from attention-deficit/hyperactivity disorder subjects.

CONCLUSIONS

While there was a significant heterogeneity in estimates between studies, a consistent pattern of elevations in inattention/hyperactivity, depression/anxiety, and aggression was identified.

Juvenile bipolar disorder in Brazil: clinical and treatment findings

BACKGROUND

Because few studies were conducted to evaluate bipolar disorder in children and adolescents outside North America, this investigation aims to describe clinical features, pattern of comorbidities, and response to pharmacologic treatment in a sample of youths with bipolar disorder (BD) from a pediatric psychopharmacology outpatient clinic in Brazil.

METHODS

We performed a retrospective chart review of all patients under age 15 with BD diagnoses who were evaluated and treated in our clinic from 1998-2001. A comparison sample of subjects with attention-deficit/hyperactivity disorder (ADHD) without BD (n = 362) was also evaluated.

RESULTS

The prevalence of juvenile BD in our sample was 7.2% (36/500) (95% confidence interval = 5.2-9.9). Irritable mood was detected in 91.7% of the bipolar patients. The main comorbidity found was ADHD (58.3%). Children with BD had significantly higher rates of abnormally elevated CBCL scores in the externalizing dimension, anxiety and depression, delinquent behavior, and aggressive behavior scales than ADHD subjects (p <.05). Most BD patients (78%) needed combination drug therapy to achieve symptomatic control.

CONCLUSIONS

Our results replicate clinical and treatment findings from U.S. investigations in a different culture demonstrating that juvenile BD is not a rare disorder in clinical samples.

Can a subtype of conduct disorder linked to bipolar disorder be identified? Integration of findings from the Massachusetts General Hospital Pediatric Psychopharmacology Research Program

Our intent was to investigate systematically the overlap between conduct disorder (CD) and bipolar disorder (BPD). We hypothesized that neither CD nor manic symptoms were secondary to the other disorder and that children with the two disorders would have correlates of both. Results from a series of programmatic studies examining phenotypic features of bipolar and conduct disorder alone or combined in probands and relatives were evaluated within and without the context of ADHD. Examination of the clinical features, patterns of psychiatric comorbidity, functioning in multiple domains, and familiality showed that children with CD and BPD had similar features of each disorder irrespective of the comorbidity with the other disorder. Our data suggest that when BPD and CD co-occur in children, both are correctly diagnosed. In these comorbid cases, CD symptoms should not be viewed as secondary to BPD, and manic symptoms should not be viewed as secondary to CD.

Externalizing disorders in consecutively referred children and adolescents with bipolar disorder

We describe a consecutive clinical sample of children and adolescents with bipolar disorder (BD), in order to define the pattern of comorbid externalizing disorders and to explore the possible influence of such a comorbidity on their cross-sectional and longitudinal clinical characteristics. The sample consisted of 59 bipolar patients: 35 males and 24 females, with a mean age 14.6 +/- 3 years (range, 7 to 18 years), diagnosed as either type I or II according to DSM-IV. All patients were screened for psychiatric disorders using historical information and a clinical interview, the Diagnostic Interview for Children and Adolescents-Revised (DICA-R). Severity and subsequent outcome of the symptomatology were recorded with the Clinical Global Impression (CGI), Severity and Improvement Scales, at the baseline and thereafter monthly for a period up to 48 months. BD disorder type I was present in 37 (62.7%) of the patients; 14 (23.7%) were affected by attention deficit-hyperactivity disorder (ADHD) and 10 (16.9%) by conduct disorder (CD). Comorbid ADHD was associated with an earlier onset of BD, while CD was highly associated with BD type I. Anxiety disorders appeared more represented in patients without CD. At the end of the observation, a lower clinical improvement was recorded in patients with CD. In our children and adolescents with BD, comorbidity with externalizing disorders such as ADHD and CD is common. The clinical implications of comorbid ADHD and CD are rather different. ADHD can be viewed as a precursor of a child-onset subtype of BD, while CD might represent a prodromal or a concomitant behavioral complication that identifies a more malignant and refractory form of BD.

Discriminative validity of the general behavior inventory using youth report

The present study investigated the ability of the General Behavior Inventory (GBI) to discriminate between diagnostic groups using youth self-report. One hundred and ninety-seven youths ages 10-17 years presenting at a midwestern urban outpatient clinic specializing in mood disorders completed the GBI as part of the intake process. Diagnoses were determined by a structured clinical interview (K-SADS) administered by either a child and adolescent psychiatrist or a research assistant trained to a high level of interrater reliability (kappa > .85). Games-Howell post hoc tests showed that the diagnostic groups significantly differed on the GBI's 2 subscales, Depression and Hypomanic-Biphasic. Logistic regression demonstrated that the scales discriminated between bipolar and disruptive behavior disorders, unipolar and bipolar depression, and mood and disruptive behavior disorders or no diagnosis. Receiver Operating Characteristic (ROC) curves further indicated the good diagnostic efficiency of the scales. Results indicate that the GBI's subscales might aid in making traditionally difficult differential diagnoses, such as between bipolar disorder and Attention Deficit Hyperactivity Disorder (ADHD) and between unipolar and bipolar depression.

Parsing the comorbidity between bipolar disorder and anxiety disorders: a familial risk analysis

BACKGROUND

A growing literature suggests that anxiety disorders (ANX) co-occur with bipolar disorder (BPD), but the nature of this overlap is unknown. Thus, we investigated the familial association between BPD and ANX among the first-degree relatives of children with BPD with and without comorbid ANX.

METHODS

We compared relatives of four proband groups defined by the presence or absence of BPD and ANX in the proband: (1) BPD + ANX (n = 23 probands, 74 relatives), (2) BPD without ANX (n = 11 probands, 38 relatives), (3) ANX without BPD (n = 48 probands, 167 relatives), and (4) controls without BPD or ANX (n = 118 probands, 385 relatives). All subjects were evaluated with structured diagnostic interviews. Diagnoses of relatives were made blind to the diagnoses of probands.

RESULTS

The results show high rates of both BPD and ANX in relatives of children with BPD + ANX. Moreover, BPD and ANX cosegregated among the relatives of children with BPD + ANX. Although relatives of both ANX proband groups (with and without BPD) had high rates of ANX, and relatives of both BPD proband groups (with and without ANX) had high rates of BPD, the combined condition BPD + ANX was the predominant form of BPD among relatives of probands with BPD + ANX.

CONCLUSIONS

These family-genetic findings suggest that the comorbid condition BPD+ANX may be a distinct clinical entity. More work is needed to evaluate whether the presence of comorbid ANX may be a marker of very early onset BPD.

Discriminative validity of a parent version of the Young Mania Rating Scale

OBJECTIVE

To examine the usefulness of a parent report version of the Young Mania Rating Scale (P-YMRS) in distinguishing bipolar disorder from other mental health conditions in children and adolescents.

METHOD

Parents of 117 youths aged 5 to 17 years presenting to an outpatient research center completed an adapted Young Mania Rating Scale (P-YMRS). Eligible subjects underwent a diagnostic evaluation including a semistructured instrument (Schedule for Affective Disorders and Schizophrenia for School-Age Children) and also a clinical evaluation by a child and adolescent psychiatrist in more than 75% of the subjects.

RESULTS

Factor analyses of the P-YMRS suggested one dimension, with a total score showing acceptable internal consistency (alpha =.75). Logistic regressions discriminated bipolar mood disorder versus unipolar disorder, versus disruptive behavior disorder, and versus any other diagnosis. Classification rates exceeded 78%, and receiver operating characteristics analyses showed good diagnostic efficiency, with areas under the curve greater than 0.82.

CONCLUSIONS

The P-YMRS may be used to derive clinically meaningful information about mood disorders in youths.

Pediatric bipolar mood disorder

The diagnosis of bipolar mood disorder (BP) in preadolescents (pediatric mania) has generated considerable controversy in terms of its estimated prevalence and validity as a diagnostic category. The relative paucity of systematic studies and the current diagnostic confusion related to the disorder are often attributed to the apparent discontinuities in the childhood versus adult presentation of the illness, namely, irritability as the predominant "mood" of mania and a continuous course of symptoms. The goal of this article is to review the current literature and identify sources of confusion relating to pediatric mania by considering results to date within a larger context that include findings from studies on (1) BP illness in adults, (2) mood disorders across the lifespan, (3) the role of development in symptom expression, and (4) patterns of heritability in psychiatric disorders. Whereas much remains to be investigated in the validation of the diagnosis for children, integrating results across studies may provide a framework for understanding the differences in the presentation of severe mood disorders in children and adults.

Unsuspected depressive mania in pre-pubertal Hispanic children referred for the treatment of 'depression' with history of social 'deviance'

BACKGROUND

Despite an emerging Literature on the mixed nature of pediatric mania, initial presentation with conduct problems continues to mislead mental health clinicians. The present report focuses on Hispanic pre-pubertal children referred for the treatment of depression in the context of conduct problems.

METHODS

Eleven boys and two girls received a structured psychiatric assessment in a practice setting to make sense of the presenting clinical complexity. Diagnoses were assigned using the DSM-IV criteria.

RESULTS

Ten of the boys and both girls met criteria for depressive mania. Their family histories were replete with affective disorder. Five (50%) of the boys and both of the girls (100%) with depressive mania had family histories of bipolar disorder. Six (60%) of the boys and neither of the girls with depressive mania had psychotic features. Those with depressive mania exhibited clear-cut circadian changes in symptomatology. Euphoria, oscillating with affective states indicative of psychic pain, was characteristically restricted to the evenings or nighttime. However, the drive to seek treatment had stemmed from social 'deviance'.

CONCLUSION

Children with depressive mania are often unrecognized in clinical settings. Boys with conduct problems may be disproportionately represented among such children. These data support Akiskal's hypothesis that externalizing (conduct) problems in clinically referred children with depression are indicative of bipolar disorder.

National Institute of Mental Health research roundtable on prepubertal bipolar disorder

OBJECTIVE

A research roundtable meeting was convened at the National Institute of Mental Health on April 27, 2000, to discuss the existing controversial areas in the diagnosis of bipolar disorder in prepubertal children.

METHOD

Invited clinicians and researchers with expertise on bipolar disorder in children were asked to share and discuss their perspectives on diagnostic issues for bipolar disorder in prepubertal children.

RESULTS

The group reached agreement that diagnosis of bipolar disorder in prepubertal children is possible with currently available psychiatric assessment instruments. In addition to phenotypes that fit DSM-IV criteria for bipolar I and bipolar II, participants agreed on the existence of other phenotypic possibilities that do not meet diagnostic criteria. Bipolar not otherwise specified (NOS) was recommended as a "working diagnosis" for the non-DSM-IV phenotype.

CONCLUSIONS

Bipolar disorder exists and can be diagnosed in prepubertal children. In children who present with both the DSM-lV and non-DSM-IV phenotypes (i.e., those given a diagnosis of bipolar-NOS), assessment should include careful evaluation of all behaviors that are impairing. Moreover, these children should be monitored systematically to explore stability and change over time in diagnosis and impairment.

Evolutionary recasting: ADHD, mania and its variants

This paper reviews clinical observations and evolutionary theory in relation to attention deficit hyperactivity disorder (ADHD) on the one hand and mania and its variants on the other. Both groups of disorders resemble each other in regard to high levels of motor activity, perhaps occurring together more often than not, and are confounded in most existing research. Making distinctions requires isolating the contribution of activity level from other characteristics such as those of flawed executive functions for ADHD or grandiosity and lapses in reciprocity for mania. High activity level is an asset throughout nature except in extreme intensities or when it amplifies the characteristics of psychopathology. Fitness, social displays, and behavioral adaptations for survival are clues to some aspects of hypomania and ADHD. While hypomania can be a competitive advantage in certain niches, it appears there can be few opportunities for ADHD to do so. Indeed, the impulsiveness seen in ADHD is probably the outcome of flaws in executive functions rather than being the cause of them. Neither lapses in executive functions nor in reciprocity are apt to be domain general but may interact sharply with each person's repertoire of psychological adaptations. The author submits that a theoretical orientation as outlined here would not only help in better understanding the disorders under consideration, but could be useful in providing new directions to treatment decisions.

Continuous performance tests are sensitive to ADHD in adults but lack specificity. A review and critique for differential diagnosis

Historically, the focus for Attention Deficit Hyperactivity Disorder (ADHD) has been on children, with considerable research and many opinions available in this area. More recently, the focus has been expanded to include ADHD in adults. Assessment of ADHD in adults is complicated by the high rate of co-occurring disorders as well as symptom overlap with a number of disorders. One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review.

Heterogeneity of childhood conduct disorder: further evidence of a subtype of conduct disorder linked to bipolar disorder

BACKGROUND

Although a small literature suggests that conduct disorder (CD) co-occurs with bipolar disorder (BPD), little is known about this overlap. Thus, we investigated the familial association of antisocial disorders (CD and/or antisocial personality disorder (ASPD)) and BPD among the first degree relatives of children with CD with and without comorbid BPD.

METHODS

We compared relatives of four proband groups defined by the presence or absence of CD and BPD in the proband: (1) CD+BPD (N=26 probands, 92 relatives; (2) BPD without CD (BPD) (N=19 probands, 53 relatives); (3) CD without BPD (CD) (N=16 probands, 58 relatives); and (4) controls without BPD or CD (N=102 probands, 338 relatives). All subjects were evaluated with structured diagnostic interviews. Diagnoses of relatives were made blind to the diagnoses of probands.

RESULTS

The results show high rates of antisocial disorders and BPD in relatives of children with CD+BPD. Moreover, antisocial disorders and BPD cosegregated among the relatives of children with CD+BPD. While relatives of both CD proband groups with and without BPD had high rates of CD/ASPD, the combined condition CD/ASPD+BPD was found exclusively among relatives of probands with CD+BPD.

LIMITATIONS

Since we pooled two datasets, subjects were not all evaluated at the same time. Also, the lack of direct psychiatric interviews with children younger than 12 may have decreased the sensitivity of some diagnoses.

CONCLUSIONS

These family-genetic findings suggest that CD and BPD represent separate disorders. Furthermore, they suggest that the comorbid condition of CD+BPD may be a distinct nosological entity. This suggests that clinicians treating CD or BPD children should consider the treatment implications of this comorbid condition.

Parsing the association between bipolar, conduct, and substance use disorders: a familial risk analysis

BACKGROUND

Bipolar disorder has emerged as a risk factor for substance use disorders (alcohol or drug abuse or dependence) in youth; however, the association between bipolar disorder and substance use disorders is complicated by comorbidity with conduct disorder. We used familial risk analysis to disentangle the association between the three disorders.

METHODS

We compared relatives of four proband groups: 1) conduct disorder + bipolar disorder, 2) bipolar disorder without conduct disorder, 3) conduct disorder without bipolar disorder, and 4) control subjects without bipolar disorder or conduct disorder. All subjects were evaluated with structured diagnostic interviews. For the analysis of substance use disorders, Cox proportional hazard survival models were utilized to compare age-at-onset distributions.

RESULTS

Bipolar disorder in probands was a risk factor for both drug and alcohol addiction in relatives, independent of conduct disorder in probands, which was a risk factor for alcohol dependence in relatives independent of bipolar disorder in probands, but not for drug dependence. The effects of bipolar disorder and conduct disorder in probands combined additively to predict the risk for substance use disorders in relatives.

CONCLUSIONS

The combination of conduct disorder + bipolar disorder in youth predicts especially high rates of substance use disorders in relatives. These findings support previous results documenting that when bipolar disorder and conduct disorder occur comorbidly, both are validly diagnosed disorders.

Mania and ADHD: comorbidity or confusion

The frequency of occurrence of prepubertal mania is contingent on how much adherence to episodic disorder with separate periods of mania and depression is required. While manic symptoms superimposed on other psychiatric disorders is not uncommon, non-comorbid bipolar disorder is rare. A number of developmental, phenomenological and assessment considerations may complicate simple extrapolation of adult criteria onto young children. Nevertheless, it is clear that a significant number of preadolescents found in outpatient and inpatient samples meet at least symptom criteria for bipolar disorder. Such children have significant comorbidity and impairment. It is likely that some may develop classical bipolar disorder, some will continue to have substantial affective and behavioral comorbidity as do some complicated bipolar adults, and some will continue to have affective lability superimposed on their other, primary psychiatric disorders. Further research and follow-up will be necessary to determine who develops which outcome.