Affective illness in children and adolescents: patterns of presentation in relation to pubertal maturation and family history

Brain-Based Predictions of Psychiatric Illness-Linked Behaviors Across the Sexes

BACKGROUND

Individual differences in functional brain connectivity can be used to predict both the presence of psychiatric illness and variability in associated behaviors. However, despite evidence for sex differences in functional network connectivity and in the prevalence, presentation, and trajectory of psychiatric illnesses, the extent to which disorder-relevant aspects of network connectivity are shared or unique across the sexes remains to be determined.

METHODS

In this work, we used predictive modeling approaches to evaluate whether shared or unique functional connectivity correlates underlie the expression of psychiatric illness-linked behaviors in males and females in data from the Adolescent Brain Cognitive Development Study (N = 5260; 2571 females).

RESULTS

We demonstrate that functional connectivity profiles predict individual differences in externalizing behaviors in males and females but predict internalizing behaviors only in females. Furthermore, models trained to predict externalizing behaviors in males generalize to predict internalizing behaviors in females, and models trained to predict internalizing behaviors in females generalize to predict externalizing behaviors in males. Finally, the neurobiological correlates of many behaviors are largely shared within and across sexes: functional connections within and between heteromodal association networks, including default, limbic, control, and dorsal attention networks, are associated with internalizing and externalizing behaviors.

CONCLUSIONS

Taken together, these findings suggest that shared neurobiological patterns may manifest as distinct behaviors across the sexes. Based on these results, we recommend that both clinicians and researchers carefully consider how sex may influence the presentation of psychiatric illnesses, especially those along the internalizing-externalizing spectrum.

Distinguishing bipolar disorder from other psychiatric disorders in children

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

What goes up must come down: the burden of bipolar depression in youth

BACKGROUND

In the pediatric bipolar disorder literature, mania has eclipsed depression as the mood state of most interest. Though depressive episodes tend to be more prevalent and persisting than manic episodes, research about the associated consequences is limited. The goal of the present study was to compare the influences of depressive and manic symptoms on domains of functioning in which youth with bipolar disorder often demonstrate deficits.

METHOD

Youth meeting DSM-IV-TR criteria for bipolar spectrum disorders (I, II, and NOS) between the ages of seven and 13 were recruited from a clinic in a large Midwestern city (N=54). Both parent and clinician report of manic and depressive symptoms were used in regression analyses to determine how each set of symptoms was related to child functioning.

RESULTS

Parent-rated child depression symptoms were associated with problem behaviors (p<0.05), and lower quality of life (p<0.001). Clinician-rated child depression was associated with greater psychiatric illness (p<0.05), lower child self-concept (p<0.001), lower quality of life (p<0.05), hopelessness (p<0.05), and suicidal ideation (p<0.05). Parent-rated mania was associated with better self-esteem (p<0.05) and physical wellbeing (p<0.05). Clinician-rated mania was associated with greater psychiatric illness (p<0.05) and physical wellbeing (p<0.05).

LIMITATIONS

The specific outcomes predicted by parent and clinician-rated symptoms vary. Though the overall story told--that bipolar depression is associated with significant impairment in youth--is consistent, further research is necessary to more fully understand the impact of each mood state.

CONCLUSION

Mania is undoubtedly destructive, but this study provides evidence to suggest that depression may be more deleterious to youths' psychosocial functioning and quality of life; more attention to understanding and ameliorating the effects of bipolar depression on youth is warranted.

Cyclothymic disorder in youth: why is it overlooked, what do we know and where is the field headed?

Cyclothymic disorder is a chronic and impairing subtype of bipolar disorder, largely neglected in pediatric research. Consequently, it is rarely diagnosed clinically despite potentially being the most prevalent form of bipolar disorder. Lack of attention has added to confusion about the diagnosis and clinical presentation of cyclothymic disorder. In pediatric studies, cyclothymic disorder is commonly grouped with 'subthreshold' presentations of bipolar disorder under the undifferentiated label 'bipolar disorder not otherwise specified'. However, research indicates that cyclothymic disorder can be reliably distinguished from the other forms of bipolar disorder and from other childhood disorders. Importantly, cyclothymic disorder may be a diathesis for more acute presentations of bipolar disorder, warranting a prominent role in dimensional models of mood and psychopathology. Current evidence suggests that cyclothymic disorder has the potential to make unique contributions to our understanding of the risk factors and outcomes associated with bipolar disorder. This potential has yet to be fully realized, limiting our knowledge and ability to intervene in a meaningful way with youth who are exhibiting symptoms of a major mood disorder. Including cyclothymic disorder in future research studies of children - particularly longitudinal outcome studies - is essential for understanding the developmental trajectory of bipolar spectrum disorders and learning how to accurately diagnosis and treat the full spectrum of bipolar disorders.

Examining the validity of cyclothymic disorder in a youth sample

BACKGROUND

Four subtypes of bipolar disorder (BP) - bipolar I, bipolar II, cyclothymia and bipolar not otherwise specified (NOS) - are defined in DSM-IV-TR. Though the diagnostic criteria for each subtype are intended for both adults and children, research investigators and clinicians often stray from the DSM when diagnosing pediatric bipolar disorder (PBD) (Youngstrom, 2009), resulting in a lack of agreement and understanding regarding the PBD subtypes.

METHODS

The present study uses the diagnostic validation method first proposed by Robins and Guze (1970) to systematically evaluate cyclothymic disorder as a distinct diagnostic subtype of BP. Using a youth (ages 5-17) outpatient clinical sample (n=827), participants with cyclothymic disorder (n=52) were compared to participants with other BP spectrum disorders and to participants with non-bipolar disorders.

RESULTS

Results indicate that cyclothymic disorder shares many characteristics with other bipolar subtypes, supporting its inclusion on the bipolar spectrum. Additionally, cyclothymia could be reliably differentiated from non-mood disorders based on irritability, sleep disturbance, age of symptom onset, comorbid diagnoses, and family history.

LIMITATIONS

There is little supporting research on cyclothymia in young people; these analyses may be considered exploratory. Gaps in this and other studies are highlighted as areas in need of additional research.

CONCLUSIONS

Cyclothymic disorder has serious implications for those affected. Though it is rarely diagnosed currently, it can be reliably differentiated from other disorders in young people. Failing to accurately diagnose cyclothymia, and other subthreshold forms of bipolar disorder, contributes to a significant delay in appropriate treatment and may have serious prognostic implications.

Suicidal behaviours in a population-based sample of French youth

OBJECTIVES

To estimate the prevalence of suicidal ideation and behaviours in a large, representative sample of French youth and to evaluate age and sex correlates.

METHOD

We surveyed a large (n = 1106) cohort of French adolescents and young adults, aged 15 to 26 years and diversified throughout France, using a mailed-in self-report questionnaire.

RESULTS

Lifetime prevalence rates for suicidal ideation, plans, and attempts were 47.2%, 14.8%, and 5.7%, respectively. Rates for female youth were higher than for male youth across the entire spectrum of suicide-related outcomes. Rates generally increased between the ages of 15 and 20 years and decreased after age 21.

CONCLUSIONS

The findings suggest that suicidal thoughts and behaviours are widespread phenomena among adolescents and constitute a major public health issue.

Sex differences in the relationship between white matter microstructure and impulsivity in adolescents

Rapid maturational brain changes occur during adolescence--a time associated with risk-taking behaviors and improvements in cognition. The present study examined the relationship between white matter (WM) microstructure, impulsive behavior and response inhibition in female and male adolescents. Twenty-one healthy adolescents underwent diffusion tensor imaging using a 3.0-T magnetic resonance imaging system. Impulse control was assessed using the Bar-On Emotional Quotient Inventory, Youth Version. Response inhibition was assessed using the Stroop Color-Word Interference Test. Fractional anisotropy (FA), a measure of WM coherence, and trace, a measure of overall diffusivity, were determined from voxels manually placed in the midline and in the left and right forward-projecting arms of the genu and the splenium of the corpus callosum. Sex-specific differences were observed for the relationship between FA and impulsive behavior in the right anterior callosum for males and in the splenium for females. Males, compared to females, displayed significantly higher FA in the left WM region. Although trace was not associated with impulse control, trace in the genu (for females) and splenium (males and females) was associated with Stroop performance. Regional differences in trace also were evident, with lower values in the splenium observed than in all other regions. Although the latter significantly improved with age, no sex differences in impulse control or in Stroop performance were detected. The present findings provide supporting evidence for sex-related differences in the development of WM microstructure during adolescence. These data further suggest a neurobiological mechanism underlying some of the emotional and cognitive changes commonly observed in males versus females during the adolescent period.

Suicidal ideation among urban nine and ten year olds

Little is known about rates and correlates of suicidal ideation among nonclinical samples of preadolescents from low-income urban backgrounds. Using the Children's Depression Inventory, we measured suicidal ideation in 131 preadolescent urban children (49% female, 90% African American/Caribbean) participating in an ongoing prospective longitudinal study of prenatal cocaine exposure and children's outcome. Suicidal ideation was reported by 14.5% of the children in this sample at 9 to 10 years of age. Children's reports of depressive symptoms, exposure to violence, and distress symptoms in response to witnessing violence were associated with suicidal ideation, but prenatal cocaine exposure, parent-rated child behavior, and caregivers' psychological distress symptoms were not. Suicidal ideation may be more prevalent among preadolescents from urban, low-income backgrounds than clinicians suspect, particularly among children exposed to violence.

Risk factors associated with the development of postpartum mood disorders

BACKGROUND

Various factors have been reported to be associated with the development of postpartum mood disorders. The relationship between postpartum mood disorders and putatively hormone-related phenomena such as premenstrual dysphoric disorder (PMDD) is unclear. This study attempts to determine whether such mood phenomena are risk factors for postpartum mood disorders.

METHODS

Postpartum women (n=1800) were assessed for risk factors for postpartum mood disorders during the first 2-4 days after parturition. Of these, 133 were defined as "high risk" and 109 as "low risk" according to fixed criteria. A structured phone diagnostic interview was performed at 6-8 weeks postpartum to assess for the presence of postpartum depression or the blues.

RESULTS

Premenstrual dysphoric disorder (PMDD), mood symptoms during the first 2-4 days postpartum, a past history of depression and mood symptoms during past oral contraceptive use, were found to be significant risk factors for postpartum mood disorders. Women at high risk for postpartum mood disorders had a 9.3-, 1.5-, 1.6- and 2.6-fold increase in risk for major depression, minor depression, the blues and adjustment disorder respectively compared to women at low risk.

LIMITATIONS

While the study design is prospective, it is limited by the retrospective assessment of risk factors.

CONCLUSIONS

This study provides preliminary evidence that putatively hormone-related phenomena such as PMDD are related to the occurrence of postpartum mood disorders. The results go some way to support the hypothesis that the etiology for postpartum mood disorders may be related to differential hormonal sensitivity. Such risk factors should be included in any assessment of the risk for these disorders.

Pediatric bipolar disorder: phenomenology and course of illness

BACKGROUND

Specific features and diagnostic boundaries of childhood bipolar disorder (BD) remain controversial, and its differentiation from other disorders challenging, owing to high comorbidity with other common childhood disorders, and frequent lack of an episodic course typical of adult BD.

METHODS

We repeatedly examined children meeting DSM-IV criteria for BD (excluding episode-duration requirements) and analyzed their clinical records to evaluate age-at-onset, family history, symptoms, course, and comorbidity.

RESULTS

Of 82 juveniles (aged 10.6 +/- 3.6 years) diagnosed with BD, 90% had a family history of mood or substance-use disorders, but only 10% of patients had been diagnosed with BD. In 74%, psychopathology was recognized before age 3, usually as mood and sleep disturbances, hyperactivity, aggression, and anxiety. At onset, dysphoric-manic and mixed presentations were most common (48%), euphoric mania less (35%), and depression least (17%). Subtype diagnoses were: BP-I (52%) > BP-II (40%) > cyclothymia (7%). DSM episode-duration criteria were met in 52% of cases, and frequent shifts of mood and energy were common.

LIMITATIONS

Partly retrospective study of clinically diagnosed referred outpatients without a comparison group.

CONCLUSIONS

Pediatric BD is often mis- or undiagnosed, although it often manifests with mood lability and sleep disturbances early in life. DSM BD criteria inconsistent with clinical findings require revision for pediatric application.