Pediatric Bipolar Disorder

Aggressive Behavior in Children and Adolescents With Bipolar Spectrum Disorder: A Systematic Review of the Prevalence, Associated Factors, and Treatment

Objective

Bipolar disorder (BD) in childhood and adolescence is associated with aggressive behaviors, which might be common and in turn associated with poor clinical outcomes. This is the first systematic review to provide a comprehensive view of the current status of the knowledge about aggressive behaviors in youth with BD.

Method

We conducted a PRISMA-compliant systematic review of studies investigating aggressive behaviors in children and adolescents with BD (PROSPERO: CRD42023431674). A systematic multi-step literature search was performed on PubMed and the Web of Science. Literature search and data extraction were carried out independently. We provided a systematic synthesis of the findings from the included studies We assessed risk of bias using a modified version of the Newcastle-Ottawa Scale for cross-sectional and cohort studies.

Results

Of the 2,277 identified records 35 were included; mean age was 12.4 years, and 57.1% were male individuals. 7 studies reported on the prevalence of aggressive behavior among BD children and adolescent population, with 5 of them reporting a prevalence of over 69.0%. Aggressive behaviors were more common in children and adolescents with BD than in those with ADHD or depression. Aggressive behaviors were associated with borderline personality disorder features and poor family functioning. Valproic acid received empirical support for its efficacy in reducing aggressive behavior in BD.

Conclusion

Aggressive behaviors are prevalent among youth with BD and warrant clinical attention and specific evidence-based management. Further research on prognostic factors and psychosocial interventions evaluated prospectively is required.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper self-identifies as living with a disability. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group.

Does the Brain Matter? Cortical Alterations in Pediatric Bipolar Disorder: A Critical Review of Structural and Functional Magnetic Resonance Studies

Pediatric bipolar disorder (PBD) is associated with significant psychosocial impairment, high use of mental health services and a high number of relapses and hospitalization. Neuroimaging techniques provide the opportunity to study the neurodevelopmental processes underlying PBD, helping to identify the endophenotypic markers of illness and early biological markers of PBD. The aim of the study is to review available studies assessing structural and functional brain correlates associated with PBD. PubMed, ISI Web of Knowledge and PsychINFO databases have been searched. Studies were included if they enrolled patients aged 0-18 years with a main diagnosis of PBD according to ICD or DSM made by a mental health professional, adopted structural and/or functional magnetic resonance as the main neuroimaging method, were written in English and included a comparison with healthy subjects. Of the 400 identified articles, 46 papers were included. Patients with PBD present functional and anatomic alterations in structures normally affecting regulations and cognition. Structural neuroimaging revealed a significant reduction in gray matter, with cortical thinning in bilateral frontal, parietal and occipital cortices. Functional neuroimaging studies reported a reduced engagement of the frontolimbic and hyperactivation of the frontostriatal circuitry. Available studies on brain connectivity in PBD patients potentially indicate less efficient connections between regions involved in cognitive and emotional functions. A greater functional definition of alteration in brain functioning of PBD patients will be useful to set up a developmentally sensitive targeted pharmacological and nonpharmacological intervention.

Amygdala structure and function in paediatric bipolar disorder and high-risk youth: A systematic review of magnetic resonance imaging findings

OBJECTIVE

Converging evidence from structural and functional magnetic resonance imaging (MRI) studies points to amygdala alteration as crucial in the development of paediatric bipolar disorder (pBP). The high number of recent studies prompted us to comprehensively evaluate findings. We aimed to systematically review structural and functional MRI studies investigating the amygdala in patients with pBP and in youth at high-risk (HR) for developing pBP.

METHODS

We searched PubMed from any time to 25 September 2020 using: 'amygdala AND (MRI OR magnetic resonance imaging) AND bipolar AND (pediatr* OR child OR children OR childhood OR adolescent OR adolescents OR adolescence OR young OR familial OR at-risk OR sibling* OR offspring OR high risk)'. In this review, we adhered to the PRISMA statement.

RESULTS

Amygdala hyperactivity to emotional stimuli is the most commonly reported finding in youth with pBP and HR compared to healthy peers (HC), whereas findings from structural MRI studies are inconsistent.

CONCLUSIONS

Hyperactivation of the amygdala might be an endophenotype of pBP.

Differentiating white matter measures that protect against vs. predispose to bipolar disorder and other psychopathology in at-risk youth

Bipolar disorder (BD) is highly heritable. Identifying objective biomarkers reflecting pathophysiological processes predisposing to, versus protecting against BD, can help identify BD risk in offspring of BD parents. We recruited 21 BD participants with a first-degree relative with BD, 25 offspring of BD parents, 27 offspring of comparison parents with non-BD psychiatric disorders, and 32 healthy offspring of healthy parents. In at-risk groups, 23 had non-BD diagnoses and 29, no Axis-I diagnoses(healthy). Five at-risk offspring who developed BD post scan(Converters) were included. Diffusion imaging(dMRI) analysis with tract segmentation identified between-group differences in the microstructure of prefrontal tracts supporting emotional regulation relevant to BD: forceps minor, anterior thalamic radiation(ATR), cingulum bundle(CB), and uncinate fasciculus(UF). BD participants showed lower fractional anisotropy (FA) in the right CB (anterior portion) than other groups (q < 0.05); and in bilateral ATR (posterior portion) versus at-risk groups (q < 0.001). Healthy, but not non-BD, at-risk participants showed significantly higher FA in bilateral ATR clusters than healthy controls (qs < 0.05). At-risk groups showed higher FA in these clusters than BD participants (qs < 0.05). Non-BD versus healthy at-risk participants, and Converters versus offspring of BD parents, showed lower FA in the right ATR cluster (qs < 0.05). Low anterior right CB FA in BD participants versus other groups might result from having BD. High bilateral ATR FA in at-risk groups, and in healthy at-risk participants, versus healthy controls might protect against BD/other psychiatric disorders. Absence of elevated right ATR FA in non-BD versus healthy at-risk participants, and in Converters versus non-converter offspring of BD parents, might lower protection against BD in at-risk groups.

Trait sensation seeking is associated with heightened beta-band oscillatory dynamics over left ventrolateral prefrontal cortex during reward expectancy

BACKGROUND

Sensation Seeking, the proclivity toward novel and stimulating experiences, is associated with greater left ventrolateral prefrontal cortex (vlPFC) activity during uncertain reward expectancy. Here, we examined relationships between sensation seeking and vlPFC oscillatory dynamics using electroencephalography (EEG).

METHODS

In 26 adolescents/young adults (16 female; 22.3 ± 1.7yrs), EEG was measured during uncertain reward expectancy. Event-related spectral perturbations (ERSP) from 15-80 Hz (beta/gamma bands) were compared as a function of uncertain reward expected value and assessed for relationships with feedback-related negativity (FRN) response to outcome feedback and response tendency measures of risk for BD.

RESULTS

Event-related synchronization (ERS) between 15-25 Hz (beta) over left vlPFC was sensitive to the expected value of uncertain reward (rho=0.46; p = 0.048), and correlated with sensation seeking (r = 0.49, p < 0.01) and feedback-related negativity (FRN), where greater beta ERS was related to larger FRN (r = -0.39, p = 0.047). FRN was also related to behavioral inhibition (r = 0.49, p < 0.01).

LIMITATIONS

It is unknown whether results may extrapolate to clinical populations, given the healthy sample used here. Further, although we have confidence that the beta-band signal we measure in this study arises from left prefrontal cortex, we largely infer a left vlPFC source.

CONCLUSIONS

These findings highlight the role of left vlPFC in evaluation of immediate rewards. We now provide a link between reward expectancy-related left vlPFC activity and the well-characterized FRN, with a known role in attentive processing. These findings can guide treatment development for mania/hypomania at-risk individuals, including transcranial alternating current stimulation.

Neural function during emotion regulation and future depressive symptoms in youth at risk for affective disorders

Affective disorders (AD, including bipolar disorder, BD, and major depressive disorder) are severe recurrent illnesses. Identifying neural markers of processes underlying AD development in at-risk youth can provide objective, "early-warning" signs that may predate onset or worsening of symptoms. Using data (n = 34) from the Bipolar Offspring Study, we examined relationships between neural response in regions supporting executive function, and those supporting self-monitoring, during an emotional n-back task (focusing on the 2-back face distractor versus the 0-back no-face control conditions) and future depressive and hypo/manic symptoms across two groups of youth at familial risk for AD: Offspring of parents with BD (n = 15, age = 14.15) and offspring of parents with non-BD psychopathology (n = 19, age = 13.62). Participants were scanned and assessed twice, approximately 4 years apart. Across groups, less deactivation in the mid-cingulate cortex during emotional regulation (Rate Ratio = 3.07(95% CI:1.09-8.66), χ²(1) = 4.48, p = 0.03) at Time-1, and increases in functional connectivity from Time-1 to 2 (Rate Ratio = 1.45(95% CI:1.15-1.84), χ²(1) = 8.69, p = 0.003) between regions that showed deactivation during emotional regulation and the right caudate, predicted higher depression severity at Time-2. Both effects were robust to sensitivity analyses controlling for clinical characteristics. Decreases in deactivation between Times 1 and 2 in the right putamen tail were associated with increases in hypo/mania at Time-2, but this effect was not robust to sensitivity analyses. Our findings reflect neural mechanisms of risk for worsening affective symptoms, particularly depression, in youth across a range of familial risk for affective disorders. They may serve as potential objective, early-warning signs of AD in youth.

A preliminary study on functional activation and connectivity during frustration in youths with bipolar disorder

OBJECTIVES

Frustration is associated with impaired attention, heightened arousal, and greater unhappiness in youths with bipolar disorder (BD) vs healthy volunteers (HV). Little is known about functional activation and connectivity in the brain of BD youths in response to frustration. This exploratory study compared BD youths and HV on attentional abilities, self-reported affect, and functional activation and connectivity during a frustrating attention task.

METHODS

Twenty BD (Mage  = 15.86) and 20 HV (Mage  = 15.55) youths completed an fMRI paradigm that differentiated neural responses during processing of frustrating feedback from neural responses during attention orienting following frustrating feedback. We examined group differences in (a) functional connectivity using amygdala, inferior frontal gyrus (IFG), and striatum as seeds and (b) whole-brain and regions of interest (amygdala, IFG, striatum) activation. We explored task performance (accuracy, reaction time), self-reported frustration and unhappiness, and correlations between these variables and irritability, depressive, and manic symptoms.

RESULTS

Bipolar disorder youths, relative to HV, exhibited positive IFG-ventromedial prefrontal cortex (vmPFC) connectivity yet failed to show negative striatum-insula connectivity during feedback processing. Irritability symptoms were positively associated with striatum-insula connectivity during feedback processing. Moreover, BD vs HV youths showed positive IFG-parahippocampal gyrus (PHG)/periaqueductal gray (PAG) connectivity and negative amygdala-cerebellum connectivity during attention orienting following frustration. BD was not associated with atypical activation patterns.

CONCLUSIONS

Positive IFG-vmPFC connectivity and striatum-insula decoupling in BD during feedback processing may mediate heightened sensitivity to reward-relevant stimuli. Elevated IFG-PAG/PHG connectivity in BD following frustration may suggest greater recruitment of attention network to regulate arousal and maintain goal-directed behavior.

Editorial: Tracing the Neural Origins of Psychopathology in Epidemiological Cohorts

The period spanning late childhood and early adulthood is of critical importance to mental health. This is a time of extensive brain reorganization, driven by interactions between environmental exposures, changes in the social role of individuals, and biologically programmed processes, which sets the foundation for adult mental function. Brain reorganization in youth is a complex phenomenon that involves multiple mechanisms at the micro-, meso-, and macroscopic levels.¹ Disruptions in any of these mechanisms have the potential to increase vulnerability to adverse mental health outcomes.

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

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

The predictive value of childhood subthreshold manic symptoms for adolescent and adult psychiatric outcomes

BACKGROUND

Childhood subthreshold manic symptoms may represent a state of developmental vulnerability to Bipolar Disorder (BD) and may also be associated with other adverse psychiatric outcomes. To test this hypothesis we examined the structure and predictive value of childhood subthreshold manic symptoms for common psychiatric disorders presenting by early adulthood.

METHODS

Subthreshold manic symptoms at age 11 years and lifetime clinical outcomes by age 19 years were ascertained in the TRacking Adolescents' Individual Lives Survey (TRAILS), a prospective Dutch community cohort. We used latent class analysis to identify subthreshold manic symptom profiles at baseline. The association between class membership and subsequent clinical diagnoses of BD (comprising BD-I, BD-II, mania and hypomania), depressive, anxiety and substance abuse disorders was determined using Cox proportional-hazard ratio (HR) models.

RESULTS

At age 11 years, we identified a normative (n=916; 47%), a mildly symptomatic (n=843; 43%) and a highly symptomatic class (n=198; 10%). Referenced to the normative class, the sex- and age-adjusted risk of new-onset BD by the age of 19 years was significantly increased in the mildly (HR=2.01, 95%CI 1.13-3.59) and highly symptomatic classes (HR=5.02, 95%CI 2.48-10.16). These estimates remained significant after further adjustments for cognitive and family function, parental socioeconomic status, parental psychiatric morbidity, and comorbid disorders at baseline (p-value for linear trend across classes<0.01). Class membership did not show significant associations with incident depressive, anxiety and substance abuse disorders in the fully adjusted regression models.

LIMITATIONS

The period of risk for adult-onset BD extends beyond the observational period of the study.

CONCLUSIONS

Elevated childhood subthreshold manic symptoms are associated with increased risk of BD by early adulthood and are therefore a potentially useful phenotype for the early identification of at-risk individuals.

Irritability in child and adolescent psychopathology: An integrative review for ICD-11

In preparation for the World Health Organization's development of the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11) chapter on Mental and Behavioral Disorders, this article reviews the literature pertaining to severe irritability in child and adolescent psychopathology. First, research on severe mood dysregulation suggests that youth with irritability and temper outbursts, among other features of hyperactivity and arousal, demonstrate cross-sectional correlates and developmental outcomes that distinguish them from youth with bipolar disorder. Second, other evidence points to an irritable dimension of Oppositional Defiant Disorder symptomatology, which is uniquely associated with concurrent and subsequent internalizing problems. In contrast to the Diagnostic and Statistical Manual of Mental Disorders' (5th ed.) Disruptive Mood Dysregulation Disorder, our review of the literature supports a different solution: a subtype, Oppositional Defiant Disorder with chronic irritability/anger (proposal included in Appendix). This solution is more consistent with the available evidence and is a better fit with global public health considerations such as harm/benefit potential, clinical utility, and cross-cultural applicability. Implications for assessment, treatment, and research are discussed.

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.

Comparative Evaluation of Child Behavior Checklist-Derived Scales in Children Clinically Referred for Emotional and Behavioral Dysregulation

BACKGROUND

We recently developed the Child Behavior Checklist-Mania Scale (CBCL-MS), a novel and short instrument for the assessment of mania-like symptoms in children and adolescents derived from the CBCL item pool and have demonstrated its construct validity and temporal stability in a longitudinal general population sample.

OBJECTIVE

The aim of this study was to evaluate the construct validity of the 19-item CBCL-MS in a clinical sample and to compare its discriminatory ability to that of the 40-item CBCL-dysregulation profile (CBCL-DP) and the 34-item CBCL-Externalizing Scale.

METHODS

The study sample comprised 202 children, aged 7-12 years, diagnosed with DSM-defined attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD), and mood and anxiety disorders based on the Diagnostic Interview Schedule for Children. The construct validity of the CBCL-MS was tested by means of a confirmatory factor analysis. Receiver operating characteristics (ROC) curves and logistic regression analyses adjusted for sex and age were used to assess the discriminatory ability relative to that of the CBCL-DP and the CBCL-Externalizing Scale.

RESULTS

The CBCL-MS had excellent construct validity (comparative fit index = 0.97; Tucker-Lewis index = 0.96; root mean square error of approximation = 0.04). Despite similar overall performance across scales, the clinical range scores of the CBCL-DP and the CBCL-Externalizing Scale were associated with higher odds for ODD and CD, while the clinical range scores of the CBCL-MS were associated with higher odds for mood disorders. The concordance rate among the children who scored within the clinical range of each scale was over 90%.

CONCLUSION

CBCL-MS has good construct validity in general population and clinical samples and is therefore suitable for both clinical practice and research.

The genetics of early-onset bipolar disorder: A systematic review

BACKGROUND

Early-onset bipolar disorder has been associated with a significantly worse prognosis than late-onset BD and has been hypothesized to be a genetically homogenous subset of BD. A sizeable number of studies have investigated early-onset BD through linkage-analyses, candidate-gene association studies, genome-wide association studies (GWAS), and analyses of copy number variants (CNVs), but this literature has not yet been reviewed.

METHODS

A systematic review was conducted using the PubMed database on articles published online before January 15, 2015 and after 1990. Separate searches were made for linkage studies, candidate gene-association studies, GWAS, and studies on CNVs.

RESULTS

Seventy-three studies were included in our review. There is a lack of robust positive findings on the genetics of early-onset BD in any major molecular genetics method.

LIMITATIONS

Early-onset populations were quite small in some studies. Variance in study methods hindered efforts to interpret results or conduct meta-analysis.

CONCLUSIONS

The field is still at an early phase for research on early-onset BD. The largely null findings mirror the results of most genetics research on BD. Although most studies were underpowered, the null findings could mean that early-onset BD may not be as genetically homogenous as has been hypothesized or even that early-onset BD does not differ genetically from adult-onset BD. Nevertheless, clinically the probabilistic developmental risk trajectories associated with early-onset that may not be primarily genetically determined continued to warrant scrutiny. Future research should dramatically expand sample sizes, use atheoretical research methods like GWAS, and standardize methods.

Frontal lobe hypoactivation in medication-free adults with bipolar II depression during response inhibition

In executive function, specifically in response inhibition, numerous studies support the essential role for the inferior frontal cortex (IFC). Hypoactivation of the IFC during response-inhibition tasks has been found consistently in subjects with bipolar disorder during manic and euthymic states. The aim of this study was to examine whether reduced IFC activation also exists in unmedicated subjects with bipolar disorder during the depressed phase of the disorder. Participants comprised 19 medication-free bipolar II (BP II) depressed patients and 20 healthy control subjects who underwent functional magnetic resonance imaging (fMRI) while performing a Go/NoGo response-inhibition task. Whole-brain analyses were conducted to assess activation differences within and between groups. The BP II depressed group, compared with the control group, showed significantly reduced activation in right frontal regions, including the IFC (Brodmann's area (BA) 47), middle frontal gyrus (BA 10), as well as other frontal and temporal regions. IFC hypoactivation may be a persistent deficit in subjects with bipolar disorder in both acute mood states as well as euthymia, thus representing a trait feature of bipolar disorder.

Differential abnormalities of functional connectivity of the amygdala and hippocampus in unipolar and bipolar affective disorders

OBJECTIVE

The amygdala and hippocampus - two structures intimately associated with mood and cognition - have been reported to exhibit altered neural activity or volume in affective disorders. We hypothesized the amygdala and hippocampus would show altered and differential patterns of connectivity in patients with bipolar (BPs) and unipolar (UPs) disorder compared to healthy volunteers.

METHOD

Thirty BPs, 34 UPs, and 66 healthy volunteers were imaged using F-18-fluorodeoxyglucose and positron emission tomography while performing an auditory continuous performance task (CPT). Normalized mean activity of the amygdala and hippocampus was correlated with the rest of the brain.

RESULTS

In BPs, the amygdalae displayed exaggerated positive metabolic correlations with prefrontal and ventral striatal areas, while the hippocampus showed a paucity of normal inter-relations compared to controls. In contrast, in UPs the amygdala was significantly negatively correlated with prefrontal and anterior cingulate cortex, while the hippocampus was significantly more positively correlated to these same prefrontal areas.

CONCLUSIONS

During a simple cognitive task, the functional connectivity of the amygdala and hippocampus, regions usually associated with emotion and memory regulation, was substantially different in affective illness compared to healthy controls whether or not there were baseline abnormalities in these areas. These striking differences in functional connectivity of amygdala and hippocampus should be further explored in ill and well states and using more specific emotion and cognitive evocative tasks.

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

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

Dimensional psychopathology in preschool offspring of parents with bipolar disorder

BACKGROUND

The purpose of this study is to compare the dimensional psychopathology, as ascertained by parental report, in preschool offspring of parents with bipolar disorder (BP) and offspring of community control parents.

METHODS

122 preschool offspring (mean age 3.3 years) of 84 parents with BP, with 102 offspring of 65 control parents (36 healthy, 29 with non-BP psychopathology), were evaluated using the Child Behavior Checklist (CBCL), the CBCL-Dysregulation Profile (CBCL-DP), the Early Childhood Inventory (ECI-4), and the Emotionality Activity Sociability (EAS) survey. Teachers' Report Forms (TRF) were available for 51 preschoolers.

RESULTS

After adjusting for confounders, offspring of parents with BP showed higher scores in the CBCL total, externalizing, somatic, sleep, aggressive, and CBCL-DP subscales; the ECI-4 sleep problem scale; and the EAS total and emotionality scale. The proportion of offspring with CBCL T-scores ≥ 2 SD above the norm was significantly higher on most CBCL subscales and the CBCL-DP in offspring of parents with BP compared to offspring of controls even after excluding offspring with attention deficit hyperactivity disorder and/or oppositional defiant disorder. Compared to offspring of parents with BP-I, offspring of parents with BP-II showed significantly higher scores in total and most CBCL subscales, the ECI-4 anxiety and sleep scales and the EAS emotionality scale. For both groups of parents, there were significant correlations between CBCL and TRF scores (r = .32-.38, p-values ≤.02).

CONCLUSIONS

Independent of categorical axis-I psychopathology and other demographic or clinical factors in both biological parents, preschool offspring of parents with BP have significantly greater aggression, mood dysregulation, sleep disturbances, and somatic complaints compared to offspring of control parents. Interventions to target these symptoms are warranted.

Clinical Guidelines on Long-Term Pharmacotherapy for Bipolar Disorder in Children and Adolescents

Bipolar disorder is a severe affective disorder which can present in adolescence, or sometimes earlier, and often requires a pharmacotherapeutic approach. The phenomenology of bipolar disorder in children and adolescents appears to differ from that of adult patients, prompting the need for specific pharmacotherapy guidelines for long-term management in this patient population. Current treatment guidelines were mainly developed based on evidence from studies in adult patients, highlighting the requirement for further research into the pharmacotherapy of children and adolescents with bipolar disorder. This review compares and critically analyzes the available guidelines, discussing the recommended medication classes, their mechanisms of action, side effect profiles and evidence base.

Neural activity to intense positive versus negative stimuli can help differentiate bipolar disorder from unipolar major depressive disorder in depressed adolescents: a pilot fMRI study

Failure to distinguish bipolar depression (BDd) from the unipolar depression of major depressive disorder (UDd) in adolescents has significant clinical consequences. We aimed to identify differential patterns of functional neural activity in BDd versus UDd and employed two (fearful and happy) facial expression/ gender labeling functional magnetic resonance imaging (fMRI) experiments to study emotion processing in 10 BDd (8 females, mean age=15.1 ± 1.1) compared to age- and gender-matched 10 UDd and 10 healthy control (HC) adolescents who were age- and gender-matched to the BDd group. BDd adolescents, relative to UDd, showed significantly lower activity to both intense happy (e.g., insula and temporal cortex) and intense fearful faces (e.g., frontal precentral cortex). Although the neural regions recruited in each group were not the same, both BDd and UDd adolescents, relative to HC, showed significantly lower neural activity to intense happy and mild happy faces, but elevated neural activity to mild fearful faces. Our results indicated that patterns of neural activity to intense positive and negative emotional stimuli can help differentiate BDd from UDd in adolescents.

Neural correlates of treatment response in depressed bipolar adolescents during emotion processing

Depressive mood in adolescents with bipolar disorder (BDd) is associated with significant morbidity and mortality, but we have limited information about neural correlates of depression and treatment response in BDd. Ten adolescents with BDd (8 females, mean age = 15.6 ± 0.9) completed two (fearful and happy) face gender labeling fMRI experiments at baseline and after 6-weeks of open treatment. Whole-brain analysis was used at baseline to compare their neural activity with those of 10 age and sex-matched healthy controls (HC). For comparisons of the neural activity at baseline and after treatment of youth with BDd, region of interest analysis for dorsal/ventral prefrontal, anterior cingulate, and amygdala activity, and significant regions identified by wholebrain analysis between BDd and HC were analyzed. There was significant improvement in depression scores (mean percentage change on the Child Depression Rating Scale-Revised 57 % ± 28). Neural activity after treatment was decreased in left occipital cortex in the intense fearful experiment, but increased in left insula, left cerebellum, and right ventrolateral prefrontal cortex in the intense happy experiment. Greater improvement in depression was associated with baseline higher activity in ventral ACC to mild happy faces. Study sample size was relatively small for subgroup analysis and consisted of mainly female adolescents that were predominantly on psychotropic medications during scanning. Our results of reduced negative emotion processing versus increased positive emotion processing after treatment of depression (improvement of cognitive bias to negative and away from positive) are consistent with the improvement of depression according to Beck's cognitive theory.

Emotional face processing in pediatric bipolar disorder: evidence for functional impairments in the fusiform gyrus

OBJECTIVE

Pediatric bipolar disorder involves poor social functioning, but the neural mechanisms underlying these deficits are not well understood. Previous neuroimaging studies have found deficits in emotional face processing localized to emotional brain regions. However, few studies have examined dysfunction in other regions of the face processing circuit. This study assessed hypoactivation in key face processing regions of the brain in pediatric bipolar disorder.

METHOD

Youth with a bipolar spectrum diagnosis (n = 20) were matched to a nonbipolar clinical group (n = 20), with similar demographics and comorbid diagnoses, and a healthy control group (n = 20). Youth participated in a functional magnetic resonance imaging (fMRI) scanning which employed a task-irrelevant emotion processing design in which processing of facial emotions was not germane to task performance.

RESULTS

Hypoactivation, isolated to the fusiform gyrus, was found when viewing animated, emerging facial expressions of happiness, sadness, fearfulness, and especially anger in pediatric bipolar participants relative to matched clinical and healthy control groups.

CONCLUSIONS

The results of the study imply that differences exist in visual regions of the brain's face processing system and are not solely isolated to emotional brain regions such as the amygdala. Findings are discussed in relation to facial emotion recognition and fusiform gyrus deficits previously reported in the autism literature. Behavioral interventions targeting attention to facial stimuli might be explored as possible treatments for bipolar disorder in youth.

SHANK3 overexpression causes manic-like behaviour with unique pharmacogenetic properties

Mutations in SHANK3 and large duplications of the region spanning SHANK3 both cause a spectrum of neuropsychiatric disorders, indicating that proper SHANK3 dosage is critical for normal brain function. However, SHANK3 overexpression per se has not been established as a cause of human disorders because 22q13 duplications involve several genes. Here we report that Shank3 transgenic mice modelling a human SHANK3 duplication exhibit manic-like behaviour and seizures consistent with synaptic excitatory/inhibitory imbalance. We also identified two patients with hyperkinetic disorders carrying the smallest SHANK3-spanning duplications reported so far. These findings indicate that SHANK3 overexpression causes a hyperkinetic neuropsychiatric disorder. To probe the mechanism underlying the phenotype, we generated a Shank3 in vivo interactome and found that Shank3 directly interacts with the Arp2/3 complex to increase F-actin levels in Shank3 transgenic mice. The mood-stabilizing drug valproate, but not lithium, rescues the manic-like behaviour of Shank3 transgenic mice raising the possibility that this hyperkinetic disorder has a unique pharmacogenetic profile.

Efficacy, long-term safety, and tolerability of ziprasidone in children and adolescents with bipolar disorder

OBJECTIVE

The purpose of this study was to evaluate the short- and long-term efficacy and safety of ziprasidone in children and adolescents with bipolar I disorder.

METHODS

Subjects 10-17 years of age with a manic or mixed episode associated with bipolar I disorder participated in a 4 week, randomized, double-blind, placebo-controlled multicenter trial (RCT) followed by a 26 week open-label extension study (OLE). Subjects were randomized 2:1 to initially receive flexible-dose ziprasidone (40-160 mg/day, based on weight) or placebo. Primary outcome was the change in Young Mania Rating Scale (YMRS) scores from baseline. Safety assessments included weight and body mass index (BMI), adverse events (AEs), vital signs, laboratory measures, electrocardiograms, and movement disorder ratings.

RESULTS

In the RCT, 237 subjects were treated with ziprasidone (n=149; mean age, 13.6 years) or placebo (n=88; mean age, 13.7 years). The estimated least squares mean changes in YMRS total (intent-to-treat population) were -13.83 (ziprasidone) and -8.61 (placebo; p=0.0005) at RCT endpoint. The most common AEs in the ziprasidone group were sedation (32.9%), somnolence (24.8%), headache (22.1%), fatigue (15.4%), and nausea (14.1%). In the OLE, 162 subjects were enrolled, and the median duration of treatment was 98 days. The mean change in YMRS score from the end of the RCT to the end of the OLE (last observation carried forward) was -3.3 (95% confidence interval, -5.0 to -1.6). The most common AEs were sedation (26.5%), somnolence (23.5%), headache (22.2%), and insomnia (13.6%). For both the RCT and the OLE, no clinically significant mean changes in movement disorder scales, BMI z-scores, liver enzymes, or fasting lipids and glucose were observed. One subject on ziprasidone in the RCT and none during the OLE had Fridericia-corrected QT interval (QTcF) ≥ 460 ms.

CONCLUSION

These results demonstrate that ziprasidone is efficacious for treating children and adolescents with bipolar disorder. Ziprasidone was generally well tolerated with a neutral metabolic profile.

CLINICAL TRIALS REGISTRY

NCT00257166 and NCT00265330 at ClinicalTrials.gov.

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

CONTEXT

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Negative emotion impairs working memory in pediatric patients with bipolar disorder type I

BACKGROUND

We investigated affect recognition and the impact of emotional valence on working memory (using happy, angry, and neutral faces) in pediatric patients with bipolar disorder (BD) and healthy control (HC) subjects.

METHOD

Subjects (N=70) consisted of unmedicated patients with BD type I (BD I, n=23) and type II (BD II, n=16) and matched HC subjects (n=31). All subjects completed tasks of emotion recognition (Chicago Pediatric Emotional Acuity Task; Chicago PEAT) and working memory for happy, angry, and neutral faces (Affective N-Back Memory Task; ANMT).

RESULTS

Compared to HC subjects, BD patients performed significantly more poorly when identifying the intensity of happy and angry expressions on the Chicago PEAT, and demonstrated working-memory impairments regardless of the type of facial emotional stimuli. Pediatric BD patients displayed the most impaired accuracy and reaction time performance with negative facial stimuli relative to neutral stimuli, but did not display this pattern with positive stimuli. Only BD I patients displayed working-memory deficits, while both BD I and BD II patients displayed emotion-identification impairments. Results remained significant after controlling for co-morbid ADHD and mood state.

CONCLUSIONS

Both BD I and BD II youth demonstrate emotion-identification deficits. BD youth also demonstrate working-memory impairments for facial stimuli irrespective of emotional valence; however, working-memory deficits were the most pronounced with negative emotional stimuli. These deficits appear to be specific to BD I patients, and suggest therefore that a more severe form of illness is characterized by more severe social-cognitive impairment.

Age-grouped differences in bipolar mania

OBJECTIVE

This review of published studies compares scores on individual items of mania rating scales that systematically recorded symptom severity in persons diagnosed with bipolar disorder to identify age-grouped differences.

METHODS

An extensive literature search identified item scores from mania rating scales, with a particular emphasis on baseline Young Mania Rating Scale (YMRS) item scores in published double-blind, placebo-controlled studies of bipolar I manic disorder. These baseline YMRS item scores were assessed as a proportion of the total YMRS score and compared by age group. Additional YMRS item/total scores in subjects with bipolar spectrum disorders were added to expand the analysis.

RESULTS

Preadolescents with bipolar disorder had significantly higher YMRS item scores than adolescents on aggression, irritability, and motor activity. Young Mania Rating Scale baseline item scores relative to the YMRS total score revealed that adolescents diagnosed with bipolar I mania scored comparatively higher than did adults on YMRS aggression and irritability items, whereas adults with bipolar I manic disorder scored comparatively higher on the grandiosity and sexual interest items. Age-grouped findings from subjects diagnosed with bipolar I, II, and Not Otherwise Specified (NOS) disorders yielded similar age-grouped results.

CONCLUSION

In age-grouped YMRS item assessments of bipolar mania, anger dyscontrol was most prominent for youth, whereas disordered thought content was paramount for adults.

Cognitive dysfunction is worse among pediatric patients with bipolar disorder Type I than Type II

BACKGROUND

  Impaired profiles of neurocognitive function have been consistently demonstrated among pediatric patients with bipolar disorder (BD), and may aid in the identification of endophenotypes across subtypes of the disorder. This study aims to determine phenotypic cognitive profiles of patients with BD Type I and II.

METHODS

  Subjects (N = 79) consisted of BD I (n = 27) and BD II (n = 19) patients and demographic and intellectually matched healthy controls (HC; n = 33) that completed a battery of neurocognitive tasks.

RESULTS

  Bipolar disorder Type I patients performed significantly more poorly compared to HC on all domains of cognitive function including attention, executive function, working memory, visual memory, and verbal learning and memory. BD I patients also performed more poorly compared to BD II patients on all domains of cognitive functioning with the exception of working memory, whereas BD II patients did poorly relative to HC only on verbal learning and memory.

CONCLUSIONS

  Findings from the current study indicate that BD I patients are characterized by more severe cognitive impairment relative to BD II patients who show an intermediate pattern of performance between BD I patients and HC. Verbal learning and memory may effectively differentiate pediatric BD patients and controls, regardless of the subtype of BD, and may serve as a cognitive endophenotype for the disorder. Additionally, these findings move us closer to developing effective cognitive interventions tailored to specific subtypes of pediatric BD patients.

Neural correlates of cognitive flexibility in children at risk for bipolar disorder

BACKGROUND

Youth with bipolar disorder (BD) show behavioral and neural deficits in cognitive flexibility; however, whether such deficits exist among youths at risk for BD has not been explored.

METHODS

The current fMRI study examined the neural basis of cognitive flexibility in BD youth (n = 28), unaffected youth at risk for BD (AR; n = 13), and healthy volunteer youth (HV; n = 21) by comparing brain activation patterns while participants performed the change task. On change trials, subjects must inhibit a prepotent response and execute an alternate one.

RESULTS

During successful change trials, both BD and AR youth had increased right ventrolateral prefrontal and inferior parietal activity, compared to HV youth. During failed change trials, both BD and AR youth exhibited increased caudate activation relative to HV youth, but BD youth showed increased activation in the subgenual anterior cingulate cortex (ACC) relative to the other two groups.

CONCLUSIONS

Abnormal activity in ventrolateral prefrontal cortex, inferior parietal cortex, and striatum during a cognitive flexibility task may represent a potential BD endophenotype, but subgenual ACC dysfunction may represent a marker of BD illness itself.

Dimensional psychopathology in offspring of parents with bipolar disorder

OBJECTIVES

To compare the dimensional psychopathology in offspring of parents with bipolar disorder (BP) with offspring of community control parents as assessed by the Child Behavior Checklist (CBCL).

METHODS

Offspring of parents with BP, who were healthy or had non-BP disorders (any psychiatric disorder other than BP; n = 319) or who had bipolar spectrum disorders (n = 35), and offspring of community controls (n = 235) ages 6-18 years were compared using the CBCL, the CBCL-Dysregulation Profile (CBCL-DP), and a sum of the CBCL items associated with mood lability. The results were adjusted for multiple comparisons and for any significant between-group demographic and clinical differences in both biological parents and offspring.

RESULTS

With few exceptions, several CBCL (e.g., Total, Internalizing, and Aggression Problems), CBCL-DP, and mood lability scores in non-BP offspring of parents with BP were significantly higher than in offspring of control parents. In addition, both groups of offspring showed significantly lower scores in most scales when compared with offspring of parents with BP who had already developed BP. Similar results were obtained when analyzing the rates of subjects with CBCL T-scores that were two standard deviations or higher above the mean.

CONCLUSIONS

Even before developing BP, offspring of parents with BP had more severe and higher rates of dimensional psychopathology than offspring of control parents. Prospective follow-up studies in non-BP offspring of parents with BP are warranted to evaluate whether these dimensional profiles are prodromal manifestations of mood or other disorders, and can predict those who are at higher risk to develop BP.

Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders provides the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility. Provided herein are lessons learned during the course of the development of the fourth edition. Noted in particular is the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses. It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine. The goal would be broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each suggestion for change to the individual patient, to public policy, and to forensic applications.

Pharmacotherapy impacts functional connectivity among affective circuits during response inhibition in pediatric mania

OBJECTIVE

The aim of the current study was to determine the influence of implicated affective circuitry disturbance in pediatric bipolar disorder (PBD) on behavioral inhibition. The differential influence of an antipsychotic and an anti-epileptic medication on the functional connectivity across affective and cognitive neural operations in PBD was examined.

METHODS

This was a six-week double blind randomized fMRI trial of risperidone plus placebo vs. divalproex plus placebo for patients with mania (n=22; 13.6 ± 2.5 years). Healthy controls (HC; n=14, 14.5 ± 2.8 years) were also scanned for normative comparison. Participants performed a response inhibition fMRI task where a motor response, already 'on the way' to execution, had to be voluntarily inhibited on trials where a stop signal was presented. Independent component analysis was used to map functional connectivity across the whole brain.

RESULTS

While there were no behavioral differences between the groups at pre- or post-drug trial, there was significant improvement on manic symptoms in the patient groups. All participants engaged an evaluative affective circuit (EAC: bilateral inferior frontal gyrus, middle frontal gyrus, anterior cingulate cortex (ACC), middle temporal gyrus, insulae, caudate and putamen) and a reactive affective circuit (RAC: bilateral occipital cortex, amygdala, medial frontal gyrus and insula) during task performance. Within the EAC, post-treatment and relative to HC, greater engagement was seen in left insula in risperidone group and left subgenual ACC in divalproex group. Within the RAC, greater baseline amygdala connectivity in patients did not alter with treatment.

CONCLUSION

EAC and RAC are two key circuits that moderate emotional influence on response inhibition in PBD. Risperidone and divalproex differentially engage the EAC. Limited change in amygdala activity with treatment in all patients indicates a likely trait deficit in PBD.

Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified

OBJECTIVE

To determine the rate of diagnostic conversion from an operationalized diagnosis of bipolar disorder not otherwise specified (BP-NOS) to bipolar I disorder (BP-I) or bipolar II disorder (BP-II) in youth over prospective follow-up and to identify factors associated with conversion.

METHOD

Subjects were 140 children and adolescents recruited from clinical referrals or advertisement who met operationalized criteria for BP-NOS at intake and participated in at least one follow-up evaluation (91% of initial cohort). Diagnoses were assessed at follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. The mean duration of follow-up was 5 years and the mean interval between assessments was 8.2 months.

RESULTS

Diagnostic conversion to BP-I or BP-II occurred in 63 subjects (45%): 32 (23%) to BP-I (nine of whom had initially converted to BP-II) and 31 to only BP-II (22%). Median time from intake to conversion was 58 weeks. First- or second-degree family history of mania or hypomania was the strongest baseline predictor of diagnostic conversion (p = .006). Over follow-up, conversion was associated with greater intensity of hypomanic symptoms and with greater exposure to specialized, intensive outpatient psychosocial treatments. There was no association between conversion and exposure to treatment with particular medication classes.

CONCLUSIONS

Children and adolescents referred with mood symptoms that meet operationalized criteria for BP-NOS, particularly those with a family history of BP, frequently progress to BP-I or BP-II. Efforts to identify these youth and effectively intervene may have the potential to curtail the progression of mood disorders in this high-risk population.

Aggression, ADHD symptoms, and dysphoria in children and adolescents diagnosed with bipolar disorder and ADHD

BACKGROUND

This study had two objectives: (1) examine characteristics of aggression in children and adolescents diagnosed with bipolar disorder and (2) determine whether the CBCL pediatric bipolar disorder profile differentiated youngsters with bipolar disorder from youngsters with ADHD.

METHOD

Children and adolescents referred to a pediatric psychopharmacology clinic were systematically evaluated for psychopathology using a psychiatrist-administered diagnostic interview, parent- and teacher-report rating scales assessing the child's behavior, and child-completed self-report scales. In this sample, 27 children and adolescents were diagnosed with bipolar disorder and 249 youngsters were diagnosed with ADHD without co-occurring bipolar disorder. These two groups were compared to determine whether there were significant differences on various measures of psychopathology.

RESULTS

Youngsters diagnosed with bipolar disorder were more verbally aggressive and exhibited higher levels of reactive aggression than youngsters with ADHD without co-occurring bipolar disorder. Youngsters with bipolar disorder also reported higher levels of depressive symptoms than youngsters with ADHD without bipolar disorder. The CBCL pediatric bipolar disorder profile did not accurately identify youngsters diagnosed with bipolar disorder.

CONCLUSIONS

The present findings present a picture of manic youngsters as verbally aggressive and argumentative, who respond with anger when frustrated. Youngsters diagnosed with bipolar disorder and ADHD exhibited significant levels of impulsive behavior and attention problems, but youngsters with bipolar disorder also exhibited significant levels of aggressive behavior and dysphoric mood. Finally, the CBCL pediatric bipolar disorder profile did not accurately identify youngsters who were diagnosed with bipolar disorder.

Prevalence of bipolar disorder in children and adolescents with attention-deficit hyperactivity disorder

BACKGROUND

Some research suggests that children with attention-deficit hyperactivity disorder (ADHD) have a higher than expected risk of bipolar affective disorder. No study has examined the prevalence of bipolar disorder in a UK sample of children with ADHD.

AIMS

To examine the prevalence of bipolar disorder in children diagnosed with ADHD or hyperkinetic disorder.

METHOD

Psychopathology symptoms and diagnoses of bipolar disorder were assessed in 200 young people with ADHD (170 male, 30 female; age 6-18 years, mean 11.15, s.d. = 2.95). Rates of current bipolar disorder symptoms and diagnoses are reported. A family history of bipolar disorder in parents and siblings was also recorded.

RESULTS

Only one child, a 9-year-old boy, met diagnostic criteria for both ICD-10 hypomania and DSM-IV bipolar disorder not otherwise specified.

CONCLUSIONS

In a UK sample of children with ADHD a current diagnosis of bipolar disorder was uncommon.

Assessing disordered thoughts in preschoolers with dysregulated mood

There is rising interest in identifying precursors to bipolar disorder symptoms, including thought disorder. Thought disorder is identified in adults through self-report and in school-aged children through parent report and child story-telling. This study is an exploration to determine if preschoolers with mood dysregulation have evidence of disordered thoughts using a story-stem completion method. Participants included two groups of 3.5-6 year-old children: 20 with mood dysregulation including manic symptoms and 11 typically developing comparison children. Children were administered story completion narratives including one story where the child character accidentally cuts him/herself while pretending to cook. The children were asked to complete the stories and their responses were analyzed for atypical themes consistent with disordered thoughts such as violence or bizarreness outside of the story or props coming to life. Thirty-five percentage of symptomatic preschoolers versus 0% of typically developing preschoolers ascribed independent actions to inanimate props (p = 0.03). Eighty percentage of symptomatic preschoolers versus 9% of typically developing preschoolers utilized props in a violent or bizarre manner outside the central story (p < 0.001). Preschool children with symptoms of dysregulated mood express themes related to the unusual use of story props which may indicate disordered thoughts. This preschool expression of dysregulated mood appears similar to and possibly continuous with school-age and adult versions of bipolar disorder.

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

OBJECTIVE

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

REVIEW PROCESS

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

OUTCOMES

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

CONCLUSIONS

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

Controversies concerning the diagnosis and treatment of bipolar disorder in children

This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the present, ending with current efforts to distinguish between a small number of children whose behaviors closely fit DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disorder with Dysphoria.Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSM's diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compromised. And because BP has a strong genetic component, the label can distract attention from the family or social context.Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much on the child's context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed consent, they must be forthcoming with families about the relevant uncertainties and complexities.

Executive function in pediatric bipolar disorder and attention-deficit hyperactivity disorder: in search of distinct phenotypic profiles

Often, there is diagnostic confusion between bipolar disorder (BD) and attention-deficit hyperactivity disorder (ADHD) in youth due to similar behavioral presentations. Both disorders have been implicated as having abnormal functioning in the prefrontal cortex; however, there may be subtle differences in the manner in which the prefrontal cortex functions in each disorder that could assist in their differentiation. Executive function is a construct thought to be a behavioral analogy to prefrontal cortex functioning. We provide a qualitative review of the literature on performance on executive function tasks for BD and ADHD in order to determine differences in task performance and neurocognitive profile. Our review found primary differences in executive function in the areas of interference control, working memory, planning, cognitive flexibility, and fluency. These differences may begin to establish a pediatric BD profile that provides a more objective means of differential diagnosis between BD and ADHD when they are not reliably distinguished by clinical diagnostic methods.

The use of lithium, valproate or lamotrigine for psychiatric conditions in children and adolescents in Norway 2004-2007 - a prescription database study

BACKGROUND

There is an increasing awareness of bipolar disorder in children and adolescents. Our study aimed to explore how common the use of lithium, valproate and lamotrigine in psychiatric conditions in children and adolescents in Norway and to describe concomitant use of other psychotropic drugs.

METHODS

The Norwegian Prescription Database (NorPD) captures all prescriptions given to individuals in ambulatory care. We investigated prescriptions for lithium, and for valproate and lamotrigine given for psychiatric conditions to children and adolescents under the age of 18 years from 2004 till 2007. We also studied other prescriptions for psychotropic drugs given to the same patients during the period. A comparison was made with the users of ADHD medication.

RESULTS

The number below 18 years treated with lithium, valproate or lamotrigine rose from 323 (0.03%) in 2004 till 454 (0.04%) in 2007. Lamotrigine increased most rapidly and lithium was most infrequently used. The users of the three drugs had often also tried antidepressants (14-42%) and atypical antipsychotics (21-51%), but true concomitant use was rarer (7-20% and 16-43% respectively). The users of ADHD medication had a much lower use of other psychotropic drugs, but quite a few users of lithium, valproate and lamotrigine had tried ADHD medication (20-26%) and even used these drugs concomitantly (15-21%).

LIMITATIONS

NorPD does not include diagnoses, and we do not know if the drugs dispensed were actually used.

CONCLUSION

Overall there has been a slight increase in the use of lamotrigine in Norway during the last four years, most likely prescribed as a mood stabilizer in bipolar disorders. Still the use among the under 14-year-olds is rare in Norway.

Early-onset bipolar spectrum disorders: diagnostic issues

Since the mid 1990s, early-onset bipolar spectrum disorders (BPSDs) have received increased attention in both the popular press and scholarly press. Rates of diagnosis of BPSD in children and adolescents have increased in inpatient, outpatient, and primary care settings. BPSDs remain difficult to diagnose, particularly in youth. The current diagnostic system makes few modifications to accommodate children and adolescents. Researchers in this area have developed specific BPSD definitions that affect the generalizability of their findings to all youth with BPSD. Despite knowledge gains from the research, BPSDs are still difficult to diagnose because clinicians must: (1) consider the impact of the child's developmental level on symptom presentation (e.g., normative behavior prevalence, environmental limitations on youth behavior, pubertal status, irritability, symptom duration); (2) weigh associated impairment and course of illness (e.g., neurocognitive functioning, failing to meet full DSM criteria, future impairment); and (3) make decisions about appropriate assessment (differentiating BPSD from medical illnesses, medications, drug use, or other psychiatric diagnoses that might better account for symptoms; comorbid disorders; informant characteristics and assessment measures to use). Research findings concerning these challenges and relevant recommendations are offered. Areas for further research to guide clinicians' assessment of children with early-onset BPSD are highlighted.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Phenomenology, longitudinal course, and outcome of children and adolescents with bipolar spectrum disorders

Pediatric bipolar disorder (BPD) significantly affects the normal emotional, cognitive, and social development. The course of children and adolescents with BPD is manifested by frequent changes in symptoms polarity showing a dimensional continuum of bipolar symptoms severity from subsyndromal to mood syndromes meeting full DSM-IV criteria. Thus, early diagnosis and treatment of pediatric bipolar is of utmost importance.

Preschool bipolar disorder

Although some empirical work has now been added to the larger body of case material, preschool bipolar disorder (BPD) remains a highly ambiguous diagnostic area. This is notable in the context of the significant progress that has been made in many other areas of psychopathology in the preschool period. While there is a need for well controlled empirical investigations in this area, a small but growing body of empirical literature suggests that some form of the disorder may arise as early as age 3. The need for large scale and focused studies of this issue is underscored by the high and increasing rates of prescriptions of atypical antipsychotics and other mood stabilizing agents for preschool children with presumptive clinical diagnosis of BPD or a related variant. Clarifying the nosology of preschool BPD may also be important to better understand of the developmental psychopathology of the disorder during childhood. Data elucidating this developmental trajectory could then inform the design of earlier potentially preventive interventions that may have implications for the disorder across the lifespan.

Clinical implications of current findings in neurodevelopment

Research in the last decade has advanced our knowledge about biological factors underlying neurodevelopmental processes in childhood. Genetic research has gone beyond mapping the human genome to identifying epigenetic factors and explicating gene-environment interactions. Biological markers of vulnerability to specific disorders have been identified. The functions of and interactions between neuroanatomic regions have been illuminated by new imaging and other noninvasive techniques, such as EEG, event-related potentials, and functional magnetic resonance imaging, that allow us to link earliest signs of disorders to neurological changes. This article provides an overview of current findings in neurodevelopment, and discusses diagnostic factors, prevention and intervention, and clinical implications.

Bipolar disorder: emotional dysregulation and neuronal vulnerability

Bipolar disorder is clinically characterized by fluctuating affect, and neuropsychologically by impairment in executive functions. Such phenomena are consistent with the centrality of emotional dysregulation and impulsivity to bipolar disorder. They are also consistent with a key role for prefrontal-subcortical (striatal-thalamic) and associated limbic circuitry in its mediation. Furthermore, there is growing data on the cellular mechanisms contributing to neuronal vulnerability in this mediating circuitry.