Child & Adolescent Bipolar
George T. Lynn, M.A., M.P.A., L.M.H.C.
AD/HD from Bipolar Disorder In Children [PDF]
Institute of Mental Health research roundtable on prepubertal bipolar disorder.
J Am Acad Child Adolesc Psychiatry 2001 Aug;40(8):871-8
research roundtable meeting was convened at the National Institute of Mental Health
on April 27, 2000, to discuss the existing controversial areas in the diagnosis
of bipolar disorder in prepubertal children. METHOD: Invited clinicians and researchers
with expertise on bipolar disorder in children were asked to share and discuss
their perspectives on diagnostic issues for bipolar disorder in prepubertal children.
RESULTS: The group reached agreement that diagnosis of bipolar disorder in prepubertal
children is possible with currently available psychiatric assessment instruments.
In addition to phenotypes that fit DSM-IV criteria for bipolar I and bipolar II,
participants agreed on the existence of other phenotypic possibilities that do
not meet diagnostic criteria. Bipolar not otherwise specified (NOS) was recommended
as a "working diagnosis" for the non-DSM-IV phenotype. CONCLUSIONS:
Bipolar disorder exists and can be diagnosed in prepubertal children. In children
who present with both the DSM-lV and non-DSM-IV phenotypes (i.e., those given
a diagnosis of bipolar-NOS), assessment should include careful evaluation of all
behaviors that are impairing. Moreover, these children should be monitored systematically
to explore stability and change over time in diagnosis and impairment." [Abstract]
EY, Miklowitz DJ.
Childhood mania, attention deficit hyperactivity
disorder and conduct disorder: a critical review of diagnostic dilemmas.
Disord. 2002 Aug;4(4):215-25.
"OBJECTIVES: Significant debate exists on
whether early onset bipolar disorder is mistakenly attributed to attention deficit
hyperactivity disorder (ADHD) or conduct disorder (CD), or whether ADHD and CD
are frequently misdiagnosed as mania. We review the literature on the extent to
which these disorders can be reliably differentiated, and describe the diagnostic
confusion that may be the result of features common to both classes of disorders.
METHODS: The review focuses on research studies that have examined whether overlapping
symptoms of bipolar disorder, ADHD, and CD contribute to misdiagnosis of the two
classes of disorders, the prevalence of early onset bipolar disorder with comorbid
ADHD or CD, and theories regarding the origins of this comorbidity. RESULTS: Reliable
and accurate diagnoses can be made despite the symptom overlap of bipolar disorder
with ADHD and CD. Children with bipolar disorder and ADHD may have a distinct
familial subtype of bipolar disorder. Some findings suggest that manic symptoms
may represent 'noise' that indicates the general severity of psychopathology in
a child or adolescent. CONCLUSIONS: Further prospective studies may confirm whether
early onset bipolarity can be successfully differentiated from ADHD or CD, whether
all three types of disorders can be recognized in comorbid cases, or whether comorbid
cases represent a distinct subtype of bipolar disorder." [Abstract]
JL, Geller B.
A prepubertal and early adolescent bipolar disorder-I
phenotype: review of phenomenology and longitudinal course.
Disord. 2003 Aug;5(4):243-56.
"OBJECTIVE: Phenomenology, assessment, longitudinal,
and psychosocial findings from an ongoing, controlled, prospective study of 93
subjects with a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP)
will be reviewed. METHODS: Unlike adult-onset bipolar disorder, for which there
were over 50 years of systematic investigations, there were a paucity of rigorous
data and much controversy and skepticism about the existence and characteristics
of prepubertal-onset mania. With this background, issues to address for investigation
of child-onset mania included the following: (i) What to do about the differentiation
of mania from attention-deficit hyperactivity disorder (ADHD). (ii) How to deal
with the ubiquity of irritability as a presenting symptom in multiple child psychiatry
disorders. (iii) Development of a research instrument to assess prepubertal manifestations
of adult mania (i.e. children do not 'max out' credit cards or have four marriages).
(iv) How to distinguish normal childhood happiness and expansiveness from pathologically
impairing elated mood and grandiosity. RESULTS: To address these issues, a PEA-BP
phenotype was defined as DSM-IV mania with elated mood and/or grandiosity as one
inclusion criterion. This criterion ensured that the diagnosis of mania was not
made using only criteria that overlapped with those for ADHD, and that subjects
had at least one of the two cardinal symptoms of mania (i.e. elated mood and grandiose
behaviors). Subjects were aged 10.9 years (SD = 2.6) and age of onset of the current
episode at baseline was 7.3 years (SD = 3.5). Validation of PEA-BP was shown by
reliable assessment, 6-month stability, and 1- and 2-year diagnostic longitudinal
outcome. PEA-BP resembled the severest form of adult-onset mania by presenting
with a chronic, mixed mania, psychotic, continuously (ultradian) cycling picture.
CONCLUSION: Counterintuitively, typical 7-year-old children with PEA-BP were more
severely ill than typical 27 year olds with adult-onset mania. Moreover, longitudinal
data strongly supported differentiation of PEA-BP from ADHD." [Abstract]
Tillman R, Geller B, Bolhofner K, Craney JL, Williams
M, Zimerman B.
Ages of onset and rates of syndromal and subsyndromal
comorbid DSM-IV diagnoses in a prepubertal and early adolescent bipolar disorder
J Am Acad Child Adolesc Psychiatry. 2003 Dec;42(12):1486-93.
To study rates and ages of onset of DSM-IV syndromal and subsyndromal comorbidity
in a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) (N =
93) compared to attention-deficit/hyperactivity disorder (ADHD) (N = 81). METHOD:
The WASH-U-KSADS was given by raters blinded to subject group separately to mothers
about their children and to children about themselves. PEA-BP was defined as DSM-IV
mania with at least one cardinal symptom of mania (elation or grandiosity) to
avoid diagnosing using only symptoms that overlapped with those for ADHD. Syndromal
diagnoses required a CGAS score of 60 or less to ensure severity at a level of
definite "caseness." RESULTS: PEA-BP subjects were aged 10.9 (SD = 2.6)
at baseline and 6.8 (SD = 3.4) at onset of first mania episode. Rates of oppositional
defiant disorder and total number of comorbidities were significantly higher in
the PEA-BP group than the ADHD group. In PEA-BP subjects, mean ages of onset of
ADHD occurred before the first manic episode, and obsessive compulsive, oppositional
defiant, social phobia, generalized anxiety, separation anxiety, and conduct disorders
occurred after. CONCLUSIONS: Onsets of ADHD before mania and of oppositional defiant
disorder/conduct disorder after mania have clinical and research implications.
These include the need to examine for mania symptoms in children with ADHD and/or
oppositional defiant disorder/conduct disorder and to develop scales to differentiate
preschool mania from ADHD. Comparison with other studies demonstrated the importance
of DSM system and severity scales in reporting comorbidity rates." [Abstract]
Pediatric bipolar mood disorder.
Behav Pediatr 2002 Feb;23(1):42-56
"The diagnosis of bipolar mood disorder
(BP) in preadolescents (pediatric mania) has generated considerable controversy
in terms of its estimated prevalence and validity as a diagnostic category. The
relative paucity of systematic studies and the current diagnostic confusion related
to the disorder are often attributed to the apparent discontinuities in the childhood
versus adult presentation of the illness, namely, irritability as the predominant
"mood" of mania and a continuous course of symptoms. The goal of this
article is to review the current literature and identify sources of confusion
relating to pediatric mania by considering results to date within a larger context
that include findings from studies on (1) BP illness in adults, (2) mood disorders
across the lifespan, (3) the role of development in symptom expression, and (4)
patterns of heritability in psychiatric disorders. Whereas much remains to be
investigated in the validation of the diagnosis for children, integrating results
across studies may provide a framework for understanding the differences in the
presentation of severe mood disorders in children and adults." [Abstract]
J, Mick E, Faraone SV, Spencer T, Wilens TE, Wozniak J.
in the validity, diagnosis and treatment of paediatric bipolar disorder.
J Neuropsychopharmacol. 2003 Sep;6(3):293-300.
"Despite ongoing controversy,
the view that paediatric bipolar disorder is rare or non-existent has been increasingly
challenged not only by case reports but also by systematic research. This research
strongly suggests that paediatric bipolar disorder may not be rare but that it
may be difficult to diagnose. Since children with bipolar disorder are likely
to become adults with bipolar disorder, the recognition and characterization of
childhood-onset bipolar disorder may help identify a meaningful developmental
subtype of bipolar disorder worthy of further investigation. As recommended by
Robins and Guze [American Journal of Psychiatry (1970), 126, 983-987], a psychiatric
disorder may be considered a valid diagnostic entity if it can be shown to have
differentiating features, evidence of familiality, specific treatment responsivity
and a unique course. The goal of this article is to review our work and the extant
literature within this framework to describe the evidence supporting bipolar disorder
in children as a valid clinical diagnosis." [Abstract]
Pediatric and adolescent bipolar disorder: medical resources.
Med Ref Serv Q 2001 Fall;20(3):31-44
"An increasing body of research
suggests the existence of early onset childhood bipolar disorder. The population
of pediatric bipolar illness may be small, but current research points to early
misdiagnosis of ADD/ADHD, and that attention deficit disorder may masquerade as
a harbinger of the mania to come. Since ADD/ADHD estimates range up to 10% of
the school population, the notion that ADD/ADHD precedes bipolar disorder leads
to a significant increase in diagnosed depressives. This in turn produces an increase
in information-seeking behaviors by parents, caregivers, and medical personnel.
Variables hindering the information-seeking process include vocabulary, tool failure,
co-morbidity, social prejudices, age issues, and environmental factors. This research
provides reliable sources, Web sites, databases, key authors, electronic groups,
and other accessible medical information in order to better serve the pediatric
bipolar community." [Abstract]
SC, Henderson-Fuller S, Akiskal HS.
Occult mood disorders in 104
consecutively presenting children referred for the treatment of attention-deficit/hyperactivity
disorder in a community mental health clinic.
J Clin Psychiatry.
2003 Oct;64(10):1170-6; quiz, 1274-6.
"OBJECTIVE: To ascertain the prevalence
of mood disorders among consecutively evaluated prepubertal children presenting
for the treatment of attention-deficit/hyperactivity disorder (ADHD) in a community
mental health clinic. METHOD: 104 children received systematic assessments designed
to identify individuals meeting the DSM-IV criteria for major depressive disorder
(MDD), mania, and ADHD. "Standard" and "modified" criteria
for mania were employed. Modified criteria, in an effort to minimize false-positive
diagnoses of mania, required the presence of euphoria and/or flight of ideas.
A child meeting the criteria for MDD or either set of criteria for mania was categorized
as having a mood disorder. Mood disorders in first-degree relatives were assessed
using a systematic interview. Data were gathered from 2000 to 2002. RESULTS: Sixty-two
children (59.6%) had a mood disorder. Compared with those who did not have a mood
disorder, they were 3.3 times more likely (54.8% vs. 16.7%) to have a family history
of any affective disorder (p <.0001) and 18.3 times more likely (43.5% vs.
2.4%) to have a family history of bipolar disorder (p <.0001). Twenty (32.3%)
of the children with and none without a mood disorder had psychotic features (p
<.0001). Compared with those meeting only the standard criteria for mania,
those meeting the modified criteria were 9.1 times more likely (69.8% vs. 7.7%)
to have a family history of an affective disorder (p <.0001) and 7.3 times
more likely (55.8% vs. 7.7%) to have a family history of bipolar disorder (p =.002).
CONCLUSION: Children who presumably have ADHD often have unrecognized affective
illness. Our findings support the view that children meeting the modified criteria
for mania have veritable bipolar disorder. These findings, which were derived
in the course of delivering routine clinical services in a community mental health
clinic, are consistent with those obtained in research settings suggesting that
children presenting with ADHD often have occult mood disorders, especially unrecognized
bipolarity. We suggest that clinicians encountering children with prominent features
of ADHD inquire about the presence of euphoria and flight of ideas. We submit
that the presence of these "classic" manifestations of mania strongly
suggests the presence of occult bipolarity, even if course of illness otherwise
markedly deviates from "classic" descriptions." [Abstract]
JL, Mrakotsky C.
Depressed preschoolers with bipolar family history:
a group at high risk for later switching to mania?
Adolesc Psychopharmacol. 2003 Summer;13(2):187-97.
"Earlier age of onset
of an episode of depression and family history of bipolar disorder (FHBPD) are
well known to be associated with increased rates of switching to mania in childhood
major depressive disorder (MDD). These findings suggest that the youngest samples
of depressed children who have FHBPD might be at very high risk for switching.
The finding of a valid depressive syndrome in preschool children has raised the
question of whether mania could also manifest at this early stage. We investigated
FHBPD among three preschool study groups: a depressed group and two nondepressed
comparison groups (attention deficit hyperactivity disorder/oppositional defiant
disorder, no disorder). Increased FHBPD was found among the depressed group. Based
on this, we explored whether the depressed subgroup with FHBPD (MDD + FHBPD) had
a unique constellation of depressive symptoms compared to the depressed subgroup
without FHBPD (MDD with no FHBPD). The MDD + FHBPD group was found to have an
increased frequency of the MDD symptom of "restlessness and moves around
a lot" as compared with the MDD with no FHBPD group. The question of whether
this symptom could be an early precursor of later mania was explored. These findings
taken together suggest that early risk factors for switching to mania may be present
in a subgroup of depressed preschoolers. Longitudinal follow-up of depressed preschool
samples to determine rates of switching to mania later in development is critical
to determine whether such findings represent early risk factors. Future studies
that directly investigate age-appropriate mania manifestations in preschool samples
are now warranted." [Abstract]
Unsuspected depressive mania in
pre-pubertal Hispanic children referred for the treatment of 'depression' with
history of social 'deviance'.
J Affect Disord 2001 Dec;67(1-3):187-92
"BACKGROUND: Despite an emerging Literature on the mixed nature of pediatric
mania, initial presentation with conduct problems continues to mislead mental
health clinicians. The present report focuses on Hispanic pre-pubertal children
referred for the treatment of depression in the context of conduct problems. METHODS:
Eleven boys and two girls received a structured psychiatric assessment in a practice
setting to make sense of the presenting clinical complexity. Diagnoses were assigned
using the DSM-IV criteria. RESULTS: Ten of the boys and both girls met criteria
for depressive mania. Their family histories were replete with affective disorder.
Five (50%) of the boys and both of the girls (100%) with depressive mania had
family histories of bipolar disorder. Six (60%) of the boys and neither of the
girls with depressive mania had psychotic features. Those with depressive mania
exhibited clear-cut circadian changes in symptomatology. Euphoria, oscillating
with affective states indicative of psychic pain, was characteristically restricted
to the evenings or nighttime. However, the drive to seek treatment had stemmed
from social 'deviance'. CONCLUSION: Children with depressive mania are often unrecognized
in clinical settings. Boys with conduct problems may be disproportionately represented
among such children. These data support Akiskal's hypothesis that externalizing
(conduct) problems in clinically referred children with depression are indicative
of bipolar disorder." [Abstract]
Spencer TJ, Biederman J, Wozniak J, Faraone SV, Wilens TE,
Parsing pediatric bipolar disorder from its associated
comorbidity with the disruptive behavior disorders.
Psychiatry 2001 Jun 15;49(12):1062-70
"The unique pattern of comorbidity
found in pediatric mania greatly complicates accurate diagnosis, the course of
the disorder, and its treatment. The pattern of comorbidity is unique by adult
standards, especially its overlap with attention-deficit/hyperactivity disorder
(ADHD), aggression, and conduct disorder. Clinically, symptoms of mania have been
discounted as severe ADHD or ignored in the context of aggressive conduct disorder.
This atypicality may lead to neglect of the mood component. The addition of high
rates of additional disorders contributes to the severe morbidity, dysfunction,
and incapacitation frequently observed in these children. A comprehensive approach
to diagnostic evaluation is the keystone to establishing an effective treatment
program because response to treatment differs with individual disorders. Recognition
of the multiplicity of disorders guides therapeutic options in these often refractory
conditions. What was previously considered refractory ADHD, oppositionality, aggression,
and conduct disorder may respond after mood stabilization. We review these issues
in this article." [Abstract]
G, Toni C, Perugi G, Travierso MC, Millepiedi S, Mucci M, Akiskal HS.
disorders in consecutively referred children and adolescents with bipolar disorder.
Psychiatry. 2003 May-Jun;44(3):184-9.
"We describe a consecutive clinical
sample of children and adolescents with bipolar disorder (BD), in order to define
the pattern of comorbid externalizing disorders and to explore the possible influence
of such a comorbidity on their cross-sectional and longitudinal clinical characteristics.
The sample consisted of 59 bipolar patients: 35 males and 24 females, with a mean
age 14.6 +/- 3 years (range, 7 to 18 years), diagnosed as either type I or II
according to DSM-IV. All patients were screened for psychiatric disorders using
historical information and a clinical interview, the Diagnostic Interview for
Children and Adolescents-Revised (DICA-R). Severity and subsequent outcome of
the symptomatology were recorded with the Clinical Global Impression (CGI), Severity
and Improvement Scales, at the baseline and thereafter monthly for a period up
to 48 months. BD disorder type I was present in 37 (62.7%) of the patients; 14
(23.7%) were affected by attention deficit-hyperactivity disorder (ADHD) and 10
(16.9%) by conduct disorder (CD). Comorbid ADHD was associated with an earlier
onset of BD, while CD was highly associated with BD type I. Anxiety disorders
appeared more represented in patients without CD. At the end of the observation,
a lower clinical improvement was recorded in patients with CD. In our children
and adolescents with BD, comorbidity with externalizing disorders such as ADHD
and CD is common. The clinical implications of comorbid ADHD and CD are rather
different. ADHD can be viewed as a precursor of a child-onset subtype of BD, while
CD might represent a prodromal or a concomitant behavioral complication that identifies
a more malignant and refractory form of BD." [Abstract]
GA, Youngstrom EA.
Clinical implications of pervasive manic symptoms
Biol Psychiatry. 2003 Jun 1;53(11):1050-8.
Prior investigations of cross-informant agreement among parents, teachers, and
clinicians about externalizing and internalizing problems have not directly addressed
agreement about manic symptoms. METHODS: We identified three groups from a large
cohort of youths, aged 8-12 years, treated on an inpatient unit. All 108 participants
met criteria for an externalizing disorder, based on a semi-structured diagnostic
interview. Of these, 49 did not have manic symptoms endorsed by either the parent
or a teacher; 34 had manic symptoms reported by the parent only, and 25 had pervasive
manic symptoms (i.e., corroborated by both sources). RESULTS: The "corroborated
mania" group consistently showed the most disruptive behavior on the inpatient
unit, the worst behavior problems on multiple scales, and the longest admission
durations. The "parent-only" group scored in the midrange on all of
these measures, with group differences typically representing small to medium
effect sizes. The "externalizing only" group consistently scored lowest
on all dependent measures, with the differences representing large to extremely
large effects when compared with the corroborated mania group and medium effects
as compared with the parent-only group. CONCLUSIONS: Youths for whom multiple
informants report manic symptoms appear likely to have more severe symptom presentation
and more complicated, refractory courses than do youths without manic symptoms."
R, Myatt T.
Is preadolescent mania the same condition as adult mania?
A British perspective.
Biol Psychiatry. 2003 Jun 1;53(11):961-9.
relatively recently, the prevailing view was that mania was uncommon in preadolescent
children. In the past 15 years, however, there has been increasing interest in
the idea that mania may be much more common at younger ages than previously recognized.
This article is concerned with the issue of whether preadolescent mania represents
the same kind of problem as adult mania. It reviews concepts of bipolar disorder
and mania in adults and preadolescents, some of the issue that arise in diagnosing
mania in children, and the evidence for continuities between preadolescent and
adult mania. The diagnosis of mania in preadolescent children often requires that
inferences are made about the meaning of some symptoms but it is not always clear
that these inferences are valid. It is concluded that the extant evidence does
not provide a clear conclusion about the links between preadolescent and adult
mania. More work is needed on the phenomenology and diagnosis of mania in children,
on its natural history and on its familial correlates." [Abstract]
Bipolar disorder in children.
Nurs Ment Health Serv 2001 Mar;39(3):12-23
"This article presents an
overview of bipolar disorder (BPD) in children, a condition that only recently
has been recognized as a legitimate diagnosis. Bipolar disorder in children is
underrecognized for many reasons including lack of awareness, diagnostic confusion,
and the different clinical picture in children. Available data strongly suggest
that prepubertal childhood BPD is a non-episodic, chronic, rapid cycling, mixed
manic state. It may be comorbid with attention-deficit/hyperactivity disorder
(ADHD) and conduct disorder (CD) or it may demonstrate features of ADHD and CD,
further complicating recognition and subsequent treatment. Treatment issues are
discussed, and some reasons for the urgency of early recognition and treatment
are explained." [Abstract]
EB, Danielyan AK, Weller RA.
Somatic treatment of bipolar disorder
in children and adolescents.
Child Adolesc Psychiatr Clin
N Am. 2002 Jul;11(3):595-617.
"The currently available data from randomized,
controlled trials and a considerable amount of open clinical data suggest that
adolescent-onset bipolar disorder probably responds to the same agents as adult-onset
bipolar disorder. Research examining psychopharmacologic treatment approaches
in the early-onset bipolar disorder is limited, however. Methodologic problems
include small sample sizes, lack of comparison groups, retrospective designs,
and lack of standardized measures. In addition, sometimes no clear differentiation
is made between mania and bipolar disorder, the latter term being used broadly
in the literature. Often the studies show that symptoms improve because of treatment,
but the functioning of the patients does not improve significantly. More research
is clearly needed in all aspects of this disorder but especially in examining
the efficacy of various types of treatment, its longitudinal course, and diagnostic
issues. The indications for, and the overall duration of, long-term maintenance
therapy need further study. Many adolescents and children with bipolar disorder
do not respond to any of the first-line pharmacologic treatments; therefore, studies
with novel agents should be extended to patients in this age range. Furthermore,
physicians will probably continue to use combination therapies when confronted
by either lack of efficacy or delayed onset of efficacy with a single agent. Thus,
such resultant drug-drug interactions also should also be systematically studied
Bellivier F, Leroux M, Henry C, Rayah F, Rouillon
F, Laplanche JL, Leboyer M.
Serotonin transporter gene polymorphism
influences age at onset in patients with bipolar affective disorder.
Neurosci Lett 2002 Dec 6;334(1):17-20
"Serotonin transporter (SLC6A4)
gene polymorphism is associated with several behavioral and psychiatric traits.
In bipolar affective disorder, two polymorphisms of the SLC6A4 gene, a variable
number of tandem repeats in the second intron and a 44 bp insertion/deletion in
the serotonin transporter gene linked polymorphic region (5-HTTLPR), have been
extensively studied. The findings are conflicting possibly because of the heterogeneity
of bipolar disorder. Early-onset bipolar disorder appears to be clinically and
genetically more homogeneous and was recently suggested to be associated with
the 5-HTTLPR polymorphism. We tested the association between two polymorphisms
of the SLC6A4 gene and age at onset (AAO) in a sample of bipolar patients. For
both SLC6A4 gene polymorphisms, AAO of subjects with different genotypes were
compared. SLC6A4 genotype distributions of different AAO groups were also compared.
The variable number of tandem repeats (VNTR) polymorphism significantly influences
the AAO but the serotonin transporter gene linked polymorphic region (5-HTTLPR)
polymorphism did not. Patients carrying at least one VNTR STin2.12 allele began
their illness later whereas patients carrying the 'ss' genotype tended to begin
their illness earlier. Differential sampling procedures may influence the proportion
of AAO subgroups in a given association study, and therefore these results may
explain the conflicting results obtained in studies of the association between
the SLC6A4 gene polymorphism and bipolar affective disorder (BPAD)." [Abstract]
B, Bolhofner K, Craney JL, Williams M, DelBello MP, Gundersen K.
functioning in a prepubertal and early adolescent bipolar disorder phenotype.
J Am Acad Child Adolesc Psychiatry 2000 Dec;39(12):1543-8
To compare psychosocial functioning (PF) in a prepubertal and early adolescent
bipolar disorder phenotype (PEA-BP) sample to two comparison groups, i.e., attention-deficit/hyperactivity
disorder (ADHD) and community controls (CC). METHOD: There were 93 PEA-BP (with
or without comorbid ADHD), 81 ADHD, and 94 CC subjects who were participants in
an ongoing study, the Phenomenology and Course of Pediatric Bipolar Disorders.
Cases in the PEA-BP and ADHD groups were outpatients obtained by consecutive new
case ascertainment, and CC subjects were from a survey conducted by the Research
Triangle Institute. To fit the study phenotype, PEA-BP subjects needed to have
current DSM-IV mania or hypomania with elation and/or grandiosity as one criterion.
Assessments for PF were by experienced research nurses who were blind to group
status. Mothers and children were separately interviewed with the Psychosocial
Schedule for School Age Children-Revised. RESULTS: Compared with both ADHD and
CC subjects, PEA-BP cases had significantly greater impairment on items that assessed
maternal-child warmth, maternal-child and paternal-child tension, and peer relationships.
CONCLUSIONS: Clinicians need to consider PF deficits when planning interventions.
In the PEA-BP group, there was a 43% rate of hypersexuality with a <1% rate
of sexual abuse, supporting hypersexuality as a manifestation of child mania."
L, Craddock N.
Is there a relationship between attention deficit
hyperactivity disorder and bipolar disorder?
J Affect Disord.
"With the increasing recognition of attention deficit
hyperactivity disorder (ADHD) in adults and psychotic disorders in children and
adolescents, the possibility of a relationship between bipolar disorder (BP) and
ADHD has attracted growing interest. This paper critically reviews the scientific
literature concerning this postulated relationship by examining evidence from
clinico-epidemiological, follow up, family and laboratory studies, including neuroimaging,
neuropsychology and genetic studies. The evidence suggests that although the diagnostic
categories of BP and ADHD appear to be unrelated, there is support for a possible
relationship between some ADHD and manic-like symptoms. However, several fundamental
methodological issues require rectification in future research in order to further
elucidate the relationship between these disorders." [Abstract]
B, Zimerman B, Williams M, Bolhofner K, Craney JL.
at prospective follow-up of adults who had prepubertal major depressive disorder.
Am J Psychiatry 2001 Jan;158(1):125-7
"OBJECTIVE: The authors' goal was
to conduct an adult follow-up of subjects who had participated in a study of nortriptyline
for childhood depression. METHOD: The study group represented 100 (90. 9%) of
the original 110 subjects and included 72 subjects who had a prepubertal diagnosis
of major depressive disorder and 28 normal comparison subjects. Subjects were
assessed with semistructured research interviews given by research nurses who
were blind to the subjects' original diagnoses. RESULTS: In the original study,
the mean age of the children with prepubertal major depressive disorder was 10.3
years (SD=1.5); at adult follow-up the mean age of these subjects was 20.7 years
(SD=2.0). At follow-up, significantly more of the subjects who had prepubertal
diagnoses of major depressive disorder (N=24 [33.3%]) than normal comparison subjects
(none) had bipolar I disorder. Subjects who had prepubertal diagnoses of major
depressive disorder also had significantly higher rates of any bipolar disorder
than normal subjects (48.6% [N=35] versus 7.1% [N=2]), major depressive disorder
(36.1% [N=26] versus 14.3% [N=4]), substance use disorders (30.6% [N=22] versus
10.7% [N=3]), and suicidality (22.2% [N=16] versus 3.6% [N=1]). Parental and grandparental
mania predicted bipolar I disorder outcomes. CONCLUSIONS: High rates of switching
to mania have implications for the treatment of depressed children. The authors
discuss the reasons for their finding a higher rate of bipolar disorder in this
outcome study than was found in the one other adult outcome study of prepubertal
major depressive disorder." [Abstract]
J, Russell R, Soriano J, Wozniak J, Faraone SV.
of children with both ADHD and mania: does ascertainment source make a difference?
J Affect Disord 1998 Nov;51(2):101-12
"OBJECTIVE: We evaluated the structural
diagnostic results of children ascertained through an ADHD diagnosis with comorbid
mania to determine if they have the same phenotype as children ascertained through
a mania diagnosis with comorbid ADHD. METHOD: We compared a sample of children
participating in a family genetic study of ADHD to a sample of children ascertained
through a study of childhood mania. RESULTS: Similar correlates of ADHD and mania
were observed in children satisfying criteria for both disorders irrespective
of ascertainment source. CONCLUSIONS: Findings suggest that children with mania
and ADHD have two disorders, their features not varying with the primary diagnostic
focus. LIMITATIONS: The results may have been limited by small sample size. CLINICAL
RELEVANCE: Because the coexistence of ADHD and mania seriously complicates the
course and treatment of children, understanding the compatibility of these disorders
has important clinical implications in the management of this population."
Geller B, Warner K, Williams M, Zimerman B.
Prepubertal and young adolescent bipolarity versus ADHD: assessment
and validity using the WASH-U-KSADS, CBCL and TRF.
Disord 1998 Nov;51(2):93-100
"BACKGROUND: This addendum to 'Prepubertal
and early adolescent bipolarity differentiate from ADHD by mania criteria; grandiose
delusions; ultra-rapid or ultradian cycling' (in this volume) provides (1) a description
of Washington University at St. Louis Kiddie Schedule for Affective Disorders
and Schizophrenia (WASH-U-KSADS) with sample sections (hypersexuality, rapid cycling);
(2) a comparison of WASH-U-KSADS to KSADS-P/L and KSADS-1986 and (3) a comparison
of WASH-U-KSADS to Child Behavior Checklist (CBCL) and Teachers Report Form (TRF)
data. METHODS: Data were from the first 60 bipolar (BP) and first 60 ADHD subjects
of 270 consecutively ascertained cases (90 BP, 90 ADHD and 90 community controls)
in the NIMH funded 'Phenomenology and Course of Pediatric Bipolarity' study. Comprehensive
assessments included the WASH-U-KSADS (administered blindly to mothers and separately
to children), CBCL and TRF. RESULTS: As reported elsewhere in this volume, WASH-U-KSADS
data significantly differentiated BP and ADHD groups. Significant differences
were also found with the parent-rated CBCL and the teacher-rated TRF, thereby
providing cross-modality and cross-informant validation of the WASH-U-KSADS. Because
of the close agreement with published CBCL data from another investigator, cross-site
validation also occurred. LIMITATIONS: Venues for consecutive ascertainment from
the lowest socioeconomic status classes were unavailable due to current health
care policies. CLINICAL RELEVANCE: CBCL and TRF data separated BP from ADHD groups,
largely by non-specific externalizing dimensions (e.g., hyperactivity, aggressivity).
Clinically relevant differentiation by categorical mania-specific criteria (e.g.,
elated mood, grandiosity, racing thoughts) occurred with WASH-U-KSADS data. Both
types of data are crucial for genetic and neurobiological studies." [Abstract]
Geller B, Williams M, Zimerman B, Frazier J, Beringer
L, Warner KL.
Prepubertal and early adolescent bipolarity differentiate
from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling.
J Affect Disord 1998 Nov;51(2):81-91
"BACKGROUND: In contrast to differential
diagnosis (ddx) of older adolescent and adult bipolarity (BP), which includes
schizophrenia and substance use disorders, the main ddx of prepubertal and early
adolescent BP is attention-deficit disorder with hyperactivity (ADHD). To address
this ddx issue, and to provide prepubertal mania manifestations, interim baseline
data are presented from the National Institute of Mental Health (NIMH)-funded
study 'Phenomenology and Course of Pediatric Bipolarity'. METHODS: Data are from
the first 60 BP and the first 60 ADHD cases from 270 consecutively ascertained
subjects (90 BP, 90 ADHD and 90 community controls). Comprehensive assessments
included the Washington University at St. Louis Kiddie and Young Adult-Schedule
for Affective Disorders and Schizophrenia--Lifetime and Present Episode Version-DSM-IV
(WASH-U-KSADS) blindly administered by nurses to mothers about their offspring
and to children/adolescents about themselves. Caseness was established by consensus
conferences that included diagnostic and impairment data, teacher and school reports,
agency records, videotapes and medical charts. RESULTS: Mean baseline age of BP
cases was 11.0+/-2.7 years and the mean age at onset of BP was 8.1+/-3.5 years.
Elated mood, grandiosity, hypersexuality, decreased need for sleep, racing thoughts
and all other mania items except hyperenergetic and distractibility were significantly
and substantially more frequent among BP than ADHD cases (e.g., elation: 86.7%
BP vs. 5.0% ADHD; grandiosity: 85.0% BP vs. 6.7% ADHD). In the BP group, 55.0%
had grandiose delusions, 26.7% had suicidality with plan/intent and 83.3% were
rapid, ultra-rapid or ultradian cyclers. LIMITATIONS: Sites for consecutive case
ascertainment from the lowest socioeconomic status classes were unavailable due
to current health care policies. CLINICAL RELEVANCE: Prepubertal and early adolescent
BP cases differentiate from ADHD by mania-specific criteria and commonly present
with ultra-rapid or ultradian cycling." [Abstract]
M, Bellivier F, McKeon P, Albus M, Borrman M, Perez-Diaz F, Mynett-Johnson L,
Feingold J, Maier W.
Age at onset and gender resemblance in bipolar
Psychiatry Res 1998 Nov 16;81(2):125-31
order to measure the intrafamilial correlation for age at onset and to examine
gender resemblance among bipolar siblings, we assessed a sample of 130 bipolar
patients belonging to 59 multiple affected sibships. To study the intrafamilial
resemblance for age at onset and gender, we used the intraclass correlation and
the sibship method, respectively. Within the whole sample, age at onset for affected
siblings was correlated (rho = 0.42, P = 0.0001). Gender was randomly distributed
among bipolar sibships, demonstrating the absence of gender resemblance among
affected siblings. The existence of an intrafamilial correlation for age at onset
among bipolar siblings suggests that this variable may assist in the identification
of more heritable forms of the illness. No intrafamilial correlation was found
for the gender of affected siblings, suggesting that familial vulnerability factors
are not gender-specific." [Abstract]
U, Dahl RE, Ryan ND, Birmaher B, Williamson DE, Rao R, Kaufman J.
in EEG sleep findings in adolescent depression: unipolar versus bipolar clinical
J Affect Disord. 2002 Aug;70(3):273-80.
EEG sleep measures in child and adolescent subjects with depression have shown
considerable variability regarding group differences between depressed and control
subjects. This investigation was designed to assess whether some of the observed
variability is related to undifferentiated unipolar and bipolar disorders in a
sample that was reported previously. METHODS: Twenty-eight adolescents who met
criteria for unipolar major depression and 35 controls with no lifetime psychiatric
disorder participated in a cross-sectional sleep polysomnography study. Approximately
7 years later, follow-up clinical evaluations were conducted in 94% of the original
cohort. Clinical course during the interval period was assessed without knowledge
of subjects' initial diagnostic and psychobiological status. Re-analysis of the
original sleep data were performed with the added information of longitudinal
clinical course. RESULTS: Depressed subjects who had a unipolar course showed
reduced REM latency, higher REM density, and more REM sleep (specifically in the
early part of the night) compared with depressed adolescents who converted to
bipolar disorder and controls who remained free from psychopathology at follow-up.
In contrast to the unipolar group, depressed subjects who would later switch to
bipolar disorder had demonstrated more stage 1 sleep and diminished stage 4 sleep.
CONCLUSIONS: These preliminary results indicate that some of the observed variability
in EEG sleep measures in adolescent depression appear to be confounded by latent
bipolar illness. The findings also suggest that sleep regulatory changes associated
with unipolar versus bipolar mood disorders may be different." [Abstract]
Faraone SV, Glatt SJ, Tsuang MT.
genetics of pediatric-onset bipolar disorder.
2003 Jun 1;53(11):970-7.
"Although bipolar disorder in adults has been
extensively studied, early-onset forms of the disorder have received less attention.
We review several lines of evidence indicating that pediatric- and early adolescent-onset
bipolar disorder cases may prove the most useful for identifying susceptibility
genes. Family studies have consistently found a higher rate of bipolar disorder
among the relatives of early-onset bipolar disorder patients than in relatives
of later-onset cases, which supports the notion of a larger genetic contribution
to the early-onset cases. Comorbid pediatric bipolar disorder and attention-deficit/hyperactivity
disorder (ADHD) may also define a familial subtype of ADHD or bipolar disorder
that is strongly influenced by genetic factors and may, therefore, be useful in
molecular genetic studies. There are no twin and adoption studies of pediatric
bipolar disorder, but the heritability of this subtype is expected to be high
given the results from family studies. Thus, pediatric- and early adolescent-onset
bipolar disorder may represent a genetically loaded and homogeneous subtype of
bipolar disorder, which, if used in genetic linkage and association studies, should
increase power to detect risk loci and alleles." [Abstract]
E, Charney DS, Towbin KE, Bhangoo RK, Pine DS.
phenotypes of juvenile mania.
Am J Psychiatry. 2003 Mar;160(3):430-7.
The authors suggest criteria for a range of narrow to broad phenotypes of bipolar
disorder in children, differentiated according to the characteristics of the manic
or hypomanic episodes, and present methods for validation of the criteria. METHOD:
Relevant literature describing bipolar disorder in both children and adults was
reviewed critically, and the input of experts was sought. RESULTS: Areas of controversy
include whether the diagnosis of bipolar disorder should require clearly demarcated
affective episodes and, if so, of what duration, and whether specific hallmark
symptoms of mania should be required for the diagnosis. The authors suggest a
phenotypic system of juvenile mania consisting of a narrow phenotype, two intermediate
phenotypes, and a broad phenotype. The narrow phenotype is exhibited by patients
who meet the full DSM-IV diagnostic criteria for hypomania or mania, including
the duration criterion, and also have hallmark symptoms of elevated mood or grandiosity.
The intermediate phenotypes include 1) hypomania or mania not otherwise specified,
in which the patient has clear episodes and hallmark symptoms, but the episodes
are between 1 and 3 days in duration, and 2) irritable hypomania or mania, in
which the patient has demarcated episodes with irritable, but not elevated, mood.
The broad phenotype is exhibited by patients who have a chronic, nonepisodic illness
that does not include the hallmark symptoms of mania but shares with the narrower
phenotypes the symptoms of severe irritability and hyperarousal. CONCLUSIONS:
The presence of distinct episodes and hallmark symptoms can be used to differentiate
clinical phenotypes of juvenile mania. The utility and validity of this system
can be tested in subsequent research." [Abstract]
KN, Kupfer DJ, Frank E, Houck PR, Grochocinski VJ, Cluss PA, Stapf DA.
of birth cohort and early age at onset of illness in a bipolar disorder case registry.
J Psychiatry. 2003 Sep;160(9):1636-42.
"OBJECTIVE: Utilizing data from
a previously characterized registry of subjects with bipolar illness, the authors
examined age at onset of the first illness episode in cohorts of subjects born
from 1900 through 1939 and from 1940 through 1959. METHOD: Demographic and clinical
characteristics at the first full episode of bipolar disorder of subjects in a
diagnostically validated voluntary bipolar disorder registry (N=1,218) were reviewed
and subjected to statistical analyses. RESULTS: The median age at onset of the
first episode of bipolar illness was lower by 4.5 years in subjects born during
or after 1940 (median age=19 years), compared with subjects born before 1940 (median
age=23.5 years). The proportion of subjects with bipolar disorder presenting with
a prepubertal onset was significantly higher in the later birth-year cohort than
in the earlier birth-year cohort. More than 50% of male and female subjects in
both cohorts had a depressive episode as the first episode of bipolar illness.
Subjects in each cohort who had a parent with major depression, bipolar disorder,
or schizophrenia experienced their first episode nearly 4 to 5 years earlier than
the other subjects in the cohort. CONCLUSIONS: Prospective epidemiological studies
conducted with bipolar disorder subjects are needed to either affirm or refute
these data on age at illness onset. If the results are affirmed, the early recognition
of prepubertal bipolar disorder will be important, so that the condition can be
treated with appropriate medications and medications that could potentially worsen
the illness course can be avoided. Similarly, early recognition of bipolar illness
is important, especially in women, to minimize use of antidepressant monotherapy
for patients with bipolar illness. Among young people presenting with major depression
as the first illness episode, a parental history of major depression, bipolar
disorder, or psychosis may be a useful pointer to future bipolar disorder. Early
recognition and appropriate treatment of bipolar illness may prevent the development
of chronicity and serious functional impairment." [Abstract]
Fergus EL, Miller RB, Luckenbaugh DA, Leverich GS,
Findling RL, Speer AM, Post RM.
Is there progression from irritability/dyscontrol
to major depressive and manic symptoms? A retrospective community survey of parents
of bipolar children.
J Affect Disord. 2003 Oct;77(1):71-8.
Although previous studies have discussed age-related changes in the presentation
of early onset bipolar illness, the developmental progression of early symptoms
remains unclear. The current study sought to trace parents' retrospective report
of yearly occurrence of symptoms in a sample of children with and without a diagnosis
of bipolar disorder in the community. METHODS: Parents retrospectively rated the
occurrence of 37 activated and withdrawn symptoms causing dysfunction for each
year of their child's life (mean age 12.6 +/- 6.9). Children were divided into
three groups based on parent report of diagnosis by a community clinician: bipolar
(n=78); non-bipolar diagnosis (n=38); and well (no psychiatric diagnosis) (n=82).
Principal components analysis was performed to understand the relationship among
the symptom variables and their potential differences among the three groups as
a function of age. RESULTS: Four symptom components were derived and these began
to distinguish children with bipolar disorder from the other groups at different
ages. Component II (irritability/dyscontrol), which included temper tantrums,
poor frustration tolerance, impulsivity, increased aggression, decreased attention
span, hyperactivity and irritability, began to distinguish bipolar children from
the others the earliest (i.e., from ages 1 to 6). The other components (I, III,
and IV) which included symptoms more typical of adult depression (I), mania (III),
and psychosis (IV), distinguished the children with a bipolar diagnosis from the
others much later (between ages 7 and 12). LIMITATIONS: The data were derived
from retrospective reports by parents of their children's symptoms on a yearly
symptom check list instrument which has not been previously utilized. Parents'
ratings were not validated by an outside rater. Moreover, the children were diagnosed
in the community and a formal diagnostic interview was not given. CONCLUSIONS:
By parental report, the cluster of symptoms in the irritability/dyscontrol component
may characterize the earliest precursors to an illness eventually associated with
more classic manic and depressive components that are diagnosed and treated as
bipolar disorder in the community. These retrospective survey data suggesting
a longitudinal evolution of symptom clusters in childhood bipolar-like illness
identify a number of areas for prospective research and validation." [Abstract]
J, Srinath S, Reddy YC, Shashikiran MG, Girimaji SC, Seshadri SP, Subbakrishna
The index manic episode in juvenile-onset bipolar disorder: the
pattern of recovery.
Can J Psychiatry. 2003 Feb;48(1):52-5.
Recent studies of patients with juvenile bipolar disorder report low rates of
recovery and high rates of chronicity. However, we lack data on the short-term
outcome. This study examines the pattern of recovery from the index episode in
an aggressively treated juvenile sample. METHOD: We assessed 25 subjects (<
16 years) with a diagnosis of mania, using the Diagnostic Interview for Children
and Adolescents-Revised) (DICA-R), Young Mania Rating Scale (YMRS), and Children's
Global Assessment Scale (CGAS) at intake and at 3 and 6 months. We studied the
time taken to recover from the index episode, the level of functioning, and the
factors predicting them. RESULTS: After 6 months, 24 (96%) subjects had recovered
from the index manic episode. The median time to recovery was 27 days. Total episode
length was significantly longer among those with previous affective episodes.
CONCLUSIONS: The findings suggest that juvenile-onset mania has high rates of
recovery and low rates of chronicity. These differences from the existing literature
need further exploration." [Abstract]
R, Geller B, Nickelsburg MJ, Bolhofner K, Craney JL, DelBello MP, Wigh W.Tillman
R, Geller B, Nickelsburg MJ, Bolhofner K, Craney JL, DelBello MP, Wigh W.
events in a prepubertal and early adolescent bipolar disorder phenotype compared
to attention-deficit hyperactive and normal controls.
Child Adolesc Psychopharmacol. 2003 Fall;13(3):243-51.
examine life events in subjects with a prepubertal and early adolescent bipolar
disorder phenotype (PEA-BP) compared to those in subjects with attention-deficit
hyperactivity disorder (ADHD) and normal controls (NC). METHODS: To optimize generalizeability,
subjects with PEA-BP (n = 93) and ADHD (n = 81) were consecutively ascertained
from pediatric and psychiatric sites. Subjects in the NC group (n = 94) were obtained
from a random survey. PEA-BP was defined by Diagnostic and Statistical Manual
of Mental Disorders (fourth edition) mania with at least one of the cardinal symptoms
of mania (i.e., elation and/or grandiosity) to avoid diagnosing mania only by
criteria that overlapped with those for ADHD. All subjects received comprehensive,
blind research assessments of mothers about their children and separately of children
about themselves. Assessment instruments included the Washington University in
St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)
and the Life Events Checklist. Data from the Life Events Checklist were examined
by total life events and by subcategories of dependent, independent, or uncertain
relationships to the child. RESULTS: Total, independent, dependent, and uncertain
life events were all significantly more frequent in the PEA-BP subjects compared
to both the ADHD and NC groups. CONCLUSIONS: Because there was no a priori reason
to expect significantly more independent life events in the PEA-BP compared to
the ADHD and NC groups, these results warrant further research into the role of
life events in the onset of PEA-BP." [Abstract]
KA, Chang KD, Blasey CM, Adleman NE, Steiner H.
of children of bipolar parents by parent report CBCL.
Psychiatr Res 2002 Sep-Oct;36(5):337-45
"In past research the Child Behavior
Checklist (CBCL) has differentiated among various diagnostic categories for children
and adolescents. However, research has not been conducted on whether the CBCL
differentiates among diagnostic categories for children at high risk for development
of psychopathology. This study compares four diagnostic groups [bipolar disorder
(BD), attention/deficit-hyperactivity disorder (ADHD), Depressed/Anxious and No
Diagnosis] within a cohort of 58 children of bipolar parents to determine whether
their CBCL scores will replicate the scores of children not at high risk for bipolar
disorder. The cohort of children of bipolar parents received elevated scores on
the CBCL scales in comparison with non-clinical populations. In addition, the
CBCL distinguished between children of bipolar parents with and without clinical
disorders. Finally the BD group differed from the ADHD group only on the Aggressive
Behaviors, Withdrawn and Anxious/Depressed subscales of the CBCL. Therefore the
CBCL did not discriminate between the BD and ADHD groups as it had in previous
studies of children with BD and unspecified family history. It is possible that
this discrepancy is due to a group of children of bipolar parents with ADHD who
are currently prodromal for bipolar disorder and therefore received higher scores
on the CBCL based on prodromal symptomatology. A longitudinal follow-up of this
cohort is necessary to ascertain whether this is the case." [Abstract]
S, Faucher B, Zarac A, Ellenbogen M.
Children of parents with bipolar
disorder. A population at high risk for major affective disorders.
Adolesc Psychiatr Clin N Am. 2002 Jul;11(3):533-53, ix.
"Children of parents
who suffer from bipolar disorder are largely ignored by psychiatric services despite
the fact that they constitute a population at very high risk for major depression
and bipolar disorder in adulthood and a wide variety of disorders in childhood
and adolescence. Major depression and bipolar disorder are chronic, recurrent
disorders that seriously impair psychosocial functioning across the life-span.
Evidence suggests that in this population bipolar disorder is preceded by externalizing
disorders in childhood in many cases, and by depression in some cases. While heredity
provides the vulnerability for the development of these characteristics, being
raised by parents who model inappropriate coping skills, create a stressful family
environment, and provide inadequate support and structure, contribute to consolidating
these characteristics." [Abstract]
KD, Blasey CM, Ketter TA, Steiner H.
of child and adolescent bipolar offspring.
J Affect Disord.
"BACKGROUND: We wished to characterize temperament
of children at high risk for bipolar disorder (BD). METHODS: We collected data
from the Dimensions of Temperament-Revised (DOTS-R) from 53 biological offspring
of at least one parent with BD. RESULTS: Overall, our cohort differed from population
means for the DOTS-R, having decreased Activity Level-General scores, and increased
Approach, and Rhythmicity-Sleep scores. Offspring with psychiatric disorders differed
from those without in having decreased Flexibility, Mood, and Task Orientation
scores. Temperament profiles for diagnostic categories of BD and attention-deficit/hyperactivity
disorder were performed in a descriptive manner. LIMITATIONS: Self- or parent-report
of temperament was used rather than clinical observation. Temperament characterization
was cross-sectional and retrospective rather than prospective and may overlap
with clinical diagnoses. CONCLUSIONS: Assessment of temperament may be useful
in characterizing bipolar offspring. Decreased flexibility and task orientation,
and presence of negative moods may be correlated with development of psychopathology."
Lewinsohn PM, Seeley JR, Buckley ME, Klein DN.
Bipolar disorder in adolescence and young adulthood.
Child Adolesc Psychiatr Clin N Am 2002 Jul;11(3):461-75, vii
of this article is to present findings from the Oregon Adolescent Depression Project
regarding full-syndrome and subthreshold bipolar disorder (BD) in adolescence
and young adulthood. BD first incidence peaked around age 14 years. Adolescent
BD showed significant continuity across developmental periods and was associated
with adverse outcomes during young adulthood. Subthreshold BD results provide
partial support for a bipolar spectrum." [Abstract]
Robertson HA, Kutcher SP, Bird D, Grasswick L.
Impact of early onset bipolar disorder on family functioning: adolescents'
perceptions of family dynamics, communication, and problems.
J Affect Disord 2001 Sep;66(1):25-37
"OBJECTIVE: This research investigated
the impact of adolescent onset bipolar illness on perceived family functioning
in stabilized bipolar I (B) and unipolar (U) probands, and normal controls (C).
METHOD: Sample N=119: 44 bipolar 1(17 M, 27 F), 30 unipolar (9 M, 21 F), and 45
controls (19 M, 26 F). Mean ages: 19.9, 18.5 and 18.2 years, respectively. INSTRUMENTS:
Family Adaptability and Cohesion Scale (FACES II), Parent-Adolescent Communication
Scales (PACS), Social Adjustment Inventory for Children and Adolescents (SAICA).
RESULTS: There were no significant group or sex differences between controls and
mood disordered youth--assessed intermorbidly--in ratings of relationship with
either parent. Bipolars acknowledged significantly more minor conflicts with parents
than either unipolars or controls. Ratings by mood disordered subjects were significantly
less positive in terms of shared activities and communication with siblings. Mood
disordered youth and controls were not differentiated on the basis of family adaptability,
and all family cohesion scores were within population norms. No significant group
differences were observed in communication with parents. LIMITATIONS: This self-report
study was conducted intermorbidly, does not include objective measures of family
functioning, nor does it assess the effect of psychiatric illness in other family
members on family functioning. CONCLUSIONS: Assessed intermorbidly, bipolar adolescents'
perceptions of family dynamics do not seem to diverge significantly from controls.
Further research is needed to investigate the impact of adolescent bipolar illness
on family life during acute phases of the illness, as well as the effect on family
functioning of psychiatric disorders in other family members." [Abstract]
G, Toni C, Perugi G, Mucci M, Millepiedi S, Akiskal HS.
disorders in children and adolescents with bipolar disorder: a neglected comorbidity.
Can J Psychiatry 2001 Nov;46(9):797-802
"OBJECTIVE: We describe a consecutive
clinical sample of children and adolescents with bipolar disorder to define the
pattern of comorbid anxiety and externalizing disorders (attention-deficit hyperactivity
disorder [ADHD] and conduct disorder [CD]) and to explore the possible influence
of such a comorbidity on their cross-sectional and longitudinal clinical characteristics.
METHODS: The sample comprised 43 outpatients, 26 boys and 17 girls, (mean age
14.9 years, SD 3.1; range 7 to 18), with bipolar disorder type I or II, according
to DSM-IV diagnostic criteria. All patients were screened for psychiatric disorders
using historical information and a clinical interview, the Diagnostic Interview
for Children and Adolescents-Revised (DICA-R). To shed light on the possible influence
of age at onset, we compared clinical features of subjects whose bipolar onset
was prepubertal or in childhood (< 12 years) with those having adolescent onset.
We also compared different subgroups with and without comorbid externalizing and
anxiety disorders. RESULTS: Bipolar disorder type I was slightly more represented
than type II (55.8% vs 44.2%). Only 11.6% of patients did not have any other psychiatric
disorder; importantly, 10 subjects (23.5%) did not show any comorbid anxiety disorder.
Comorbid externalizing disorders were present in 12 (27.9%) patients; such comorbidity
was related to the childhood onset of bipolar disorder type II. Compared with
other subjects, patients with comorbid anxiety disorders more often reported pharmacologic
J, Biederman J, Richards JA.
Diagnostic and therapeutic dilemmas
in the management of pediatric-onset bipolar disorder.
J Clin Psychiatry 2001;62 Suppl 14:10-5
"Although the diagnosis of pediatric-onset
bipolar disorder is controversial, an increasing literature of systematic research
has challenged the traditional view that this disorder is a rare condition. This
article summarizes research regarding the atypical presentation of pediatric bipolar
disorder and its overlap with attention-deficit/hyperactivity disorder and other
comorbid conditions, as well as family-genetic and treatment data. When structured
interview data were examined, cases of pediatric mania constituted 16% of referrals
to our outpatient clinic. Presentation is atypical by adult standards and includes
irritability, chronicity, and mixed state. Family-genetic and treatment data help
to establish diagnostic validity. Pediatric bipolar disorder is not a rare condition.
Treatment requires a combined pharmacotherapy approach to address issues of comorbidity."
MP, Soutullo CA, Hendricks W, Niemeier RT, McElroy SL, Strakowski SM.
Prior stimulant treatment in adolescents with bipolar disorder: association
with age at onset.
Bipolar Disord 2001 Apr;3(2):53-7
"OBJECTIVES: To compare demographic and clinical characteristics between
bipolar adolescents with and without a history of stimulant treatment, we hypothesized
that adolescents treated with stimulants would have an earlier age at onset of
bipolar disorder, independent of co-occurring attention-deficit-hyperactivity
disorder (ADHD). METHOD: Thirty-four adolescents hospitalized with mania were
assessed using the Washington University at St Louis Kiddie Schedule for Affective
Disorders and Schizophrenia (WASH-U-KSADS). We systematically evaluated age at
onset of bipolar disorder and pharmacological treatment history. RESULTS: Bipolar
adolescents with a history of stimulant exposure prior to the onset of bipolar
disorder had an earlier age at onset of bipolar disorder than those without prior
stimulant exposure. Additionally, bipolar adolescents treated with at least two
stimulant medications had a younger age at onset compared with those who were
treated with one stimulant. There was no difference in age at onset of bipolar
disorder between bipolar adolescents with and without ADHD. CONCLUSIONS: Our results
suggest that stimulant treatment, independent of ADHD, is associated with younger
age at onset of bipolar disorder. A behavioral sensitization model is proposed
to explain our findings. There are several limitations to our study including
the small sample size, the retrospective assessment of stimulant exposure and
age at onset of bipolar disorder, and the inclusion of only hospitalized patients,
who may be more likely to present with a severe illness. Nonetheless, future prospective
longitudinal investigations that systematically assess the effects of stimulant
medications in children with or at genetic risk for bipolar disorder are warranted."
CA, DelBello MP, Ochsner JE, McElroy SL, Taylor SA, Strakowski SM, Keck PE Jr.
of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant
J Affect Disord. 2002 Aug;70(3):323-7.
Childhood bipolarity (BP) and ADHD frequently co-occur, these children often receive
stimulants. METHOD: We retrospectively evaluated 80 adolescents hospitalized with
BP, manic or mixed, assessed severity of hospital course, and compared groups
according to current/past stimulant or antidepressant treatment. RESULTS: Lifetime
ADHD rate was 49%; 35% of patients had exposure to stimulants and 44% to antidepressants.
Stimulant-exposed patients were younger than non-exposed (mean+/-S.D.=13.7+/-2
vs. 15.1+/-2 years, Z=-3.1, P=0.002). Only stimulant exposure was associated with
worse hospitalization course (MANCOVA, Wilks' Lambda=0.87, F=3.4; df=70; P=0.02).
CONCLUSION: Stimulant-exposed BP-adolescents may have more severe illness course
not fully explained by ADHD comorbidity. LIMITATIONS: Retrospective methodology
and lack of structured interviewing make it difficult to quantify exposure to
stimulants and antidepressants." [Abstract]
GA, Jensen PS, Findling RL, Meyer RE, Calabrese J, DelBello MP, Emslie G, Flynn
L, Goodwin F, Hellander M, Kowatch R, Kusumakar V, Laughren T, Leibenluft E, McCracken
J, Nottelmann E, Pine D, Sachs G, Shaffer D, Simar R, Strober M, Weller EB, Wozniak
J, Youngstrom EA.
Methodological issues and controversies in clinical
trials with child and adolescent patients with bipolar disorder: report of a consensus
J Child Adolesc Psychopharmacol. 2003 Spring;13(1):13-27.
To achieve consensus among researchers, pharmaceutical industry representatives,
federal regulatory agency staff, and family advocates on a template for clinical
trials of acute mania/bipolar disorder in children and adolescents. METHOD: The
American Academy of Child and Adolescent Psychiatry, in collaboration with Best
Practice, convened a group of experts from the key stakeholder communities (including
adult psychiatrists with expertise in bipolar disorder) and assigned them to workgroups
to examine core methodological issues surrounding the design of clinical trials
and, ultimately, to generate a consensus statement encompassing: (1) inclusion/exclusion
criteria, (2) investigator training needs and site selection, (3) assessment and
outcome measures, (4) protocol design and ethical issues unique to trials involving
children/adolescents, and (5) regulatory agency perspectives on these deliberations.
RESULTS: Conference participants reached agreement on 18 broad methodological
questions. Key points of consensus were to assign priority to placebo-controlled
studies of acute manic episodes in children and adolescents aged 10-17 years,
who may or may not be hospitalized, and who may or may not suffer from common
comorbid psychiatric disorders; to require that specialist diagnostic "gatekeepers"
screen youths' eligibility to participate in trials; to monitor interviewer and
rater competency over the course of the trial using agreed upon standards; and
to develop new tools for assessment, including scales to measure aggression/rage
and cognitive function, while using the best available instruments (e.g., Young
Mania Rating Scale) in the interim. CONCLUSIONS: Methodologically rigorous, large-scale
clinical trials of treatment of acute mania are urgently needed to provide information
regarding the safety and efficacy, in youth, of diverse agents with potential
mood-stabilizing properties." [Abstract]
J, Monuteaux M, Richards J, E Lail K, Faraone SV, Biederman J.
between structured diagnostic interviews and clinical assessment on the diagnosis
of pediatric-onset mania.
Biol Psychiatry. 2003 Jun 1;53(11):938-44.
Uncertainties remain as to the utility of structured diagnostic methodology to
aid in the diagnosis of manic symptomatology in youth. To this end, this study
compared structured diagnostic interview based diagnoses of mania in children
and adolescents with that of an expert clinician. METHODS: We separately and independently
assessed 69 youths recruited for a study of mania in childhood, all but 2 of whom
experienced mania, with a structured diagnostic interview administered by trained
psychometricians and a clinical assessment by a board-certified child and adolescent
psychiatrist (JW) who was blind to the structured interview results. RESULTS:
Structured interviews and clinical evaluations converged in all but two cases
(67 of 69 or 97% agreement). In one discrepant case, the structured interview
diagnosed a full case of mania, but the clinical interview diagnosed cyclothymia/subthreshold
mania; in the other discrepant case, the structured interview failed to diagnose
mania, but the clinical interview did diagnose mania. CONCLUSIONS: In children
referred for evaluation of suspected bipolar disorder, a structured interview
diagnosis of mania is very likely to be corroborated by a clinical interview."
B, Zimerman B, Williams M, Bolhofner K, Craney JL, DelBello MP, Soutullo C.
Reliability of the Washington University in St. Louis Kiddie Schedule
for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling
J Am Acad Child Adolesc Psychiatry 2001 Apr;40(4):450-5
"OBJECTIVE: To investigate the reliability of the Washington University in
St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)
mania and rapid cycling sections. METHOD: The 1986 version of the KSADS was modified
and expanded to include onset and offset of each symptom for both current and
lifetime episodes, expanded prepubertal mania and rapid cycling sections, and
categories for attention-deficit/hyperactivity disorder and other DSM-IV diagnoses.
To optimize diagnostic research, skip-outs were minimized. Subjects participated
in the ongoing "Phenomenology and Course of Pediatric Bipolar Disorder"
study. Mothers and children were interviewed separately by research nurses who
were blind to diagnostic group status. In addition, ratings of off-site child
psychiatrists, made from the narrative documentation given for each WASH-U-KSADS
item, were compared with research nurse ratings. This work was performed between
1995 and 2000. RESULTS: There was 100% interrater reliability, five consecutive
times, as both interviewer and observer after 10 to 15 trials. The kappa values
of comparisons between research nurse and off-site blind best-estimate ratings
of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability
for mania diagnoses (85.7%) and for individual mania items and validity against
parental and teacher reports were previously reported. CONCLUSIONS: The WASH-U-KSADS
mania and rapid cycling sections have acceptable reliability." [Abstract]
DP, Treland JE, Snow J, McClure EB, Mehta MS, Towbin KE, Pine DS, Leibenluft E.
performance in pediatric bipolar disorder.
2004 Jan 1;55(1):32-9.
"BACKGROUND: Growing awareness of childhood bipolar
disorder necessitates further cognitive neuroscience research to determine unique
developmental differences between pediatric and adult onset bipolar disorder.
We sought to examine whether neuropsychological function in children with bipolar
disorder resembles that in adults with the illness and to extend our knowledge
about cognitive function in pediatric bipolar disorder. METHODS: We administered
a computerized neuropsychological test battery known as the Cambridge Neuropsychological
Test Automated Battery to a sample of 21 children and adolescents with bipolar
disorder and compared them with 21 age- and gender-matched controls. RESULTS:
In comparison to controls, children with bipolar disorder were impaired on measures
of attentional set-shifting and visuospatial memory. Post hoc analyses in pediatric
bipolar disorder subjects did not show significant associations between neuropsychological
performance and manic symptomatology or attention-deficit/hyperactivity disorder
comorbidity. CONCLUSIONS: Cambridge Neuropsychological Test Automated Battery
data presented here in pediatric bipolar disorder fit well within the broader
framework of known neurocognitive deficits in adult bipolar disorder. Our pediatric
bipolar disorder subjects demonstrated selective deficiencies in attentional set-shifting
and visuospatial memory. Our work suggests altered ventrolateral prefrontal cortex
function, especially when linked to other lesion and neuroimaging studies."
Biederman J, Mick E, Wozniak J, Monuteaux MC, Galdo
M, Faraone SV.
Can a subtype of conduct disorder linked to bipolar
disorder be identified? Integration of findings from the Massachusetts General
Hospital Pediatric Psychopharmacology Research Program.
Psychiatry. 2003 Jun 1;53(11):952-60.
"Our intent was to investigate systematically
the overlap between conduct disorder (CD) and bipolar disorder (BPD). We hypothesized
that neither CD nor manic symptoms were secondary to the other disorder and that
children with the two disorders would have correlates of both. Results from a
series of programmatic studies examining phenotypic features of bipolar and conduct
disorder alone or combined in probands and relatives were evaluated within and
without the context of ADHD. Examination of the clinical features, patterns of
psychiatric comorbidity, functioning in multiple domains, and familiality showed
that children with CD and BPD had similar features of each disorder irrespective
of the comorbidity with the other disorder. Our data suggest that when BPD and
CD co-occur in children, both are correctly diagnosed. In these comorbid cases,
CD symptoms should not be viewed as secondary to BPD, and manic symptoms should
not be viewed as secondary to CD." [Abstract]
J, Faraone SV, Wozniak J, Monuteaux MC.
Parsing the association
between bipolar, conduct, and substance use disorders: a familial risk analysis.
Biol Psychiatry 2000 Dec 1;48(11):1037-44
"BACKGROUND: Bipolar disorder
has emerged as a risk factor for substance use disorders (alcohol or drug abuse
or dependence) in youth; however, the association between bipolar disorder and
substance use disorders is complicated by comorbidity with conduct disorder. We
used familial risk analysis to disentangle the association between the three disorders.
METHODS: We compared relatives of four proband groups: 1) conduct disorder + bipolar
disorder, 2) bipolar disorder without conduct disorder, 3) conduct disorder without
bipolar disorder, and 4) control subjects without bipolar disorder or conduct
disorder. All subjects were evaluated with structured diagnostic interviews. For
the analysis of substance use disorders, Cox proportional hazard survival models
were utilized to compare age-at-onset distributions. RESULTS: Bipolar disorder
in probands was a risk factor for both drug and alcohol addiction in relatives,
independent of conduct disorder in probands, which was a risk factor for alcohol
dependence in relatives independent of bipolar disorder in probands, but not for
drug dependence. The effects of bipolar disorder and conduct disorder in probands
combined additively to predict the risk for substance use disorders in relatives.
CONCLUSIONS: The combination of conduct disorder + bipolar disorder in youth predicts
especially high rates of substance use disorders in relatives. These findings
support previous results documenting that when bipolar disorder and conduct disorder
occur comorbidly, both are validly diagnosed disorders." [Abstract]
LA, Harris SK, Kurland M, Knight JR.
Substance use problems and associated
psychiatric symptoms among adolescents in primary care.
2003 Jun;111(6 Pt 1):e699-705.
"OBJECTIVE: Substance use disorders (SUDs)
are associated with other mental disorders in adolescence, but it is unclear whether
less severe substance use problems (SUPs) also increase risk. Because youths with
SUPs are most likely to present first to their site of primary care, it is important
to establish the presence and patterns of psychiatric comorbidity among adolescent
primary care patients with subdiagnostic use of alcohol or other drugs. The objective
of this study was to determine the association between level of substance use
and psychiatric symptoms among adolescents in a primary care setting. METHODS:
Patients who were aged 14 to 18 years and receiving routine care at a hospital-based
adolescent clinic were eligible. Participants completed the Problem Oriented Screening
Instrument for Teenagers Substance Use/Abuse scale, which is designed to detect
social and legal problems associated with alcohol and other drugs, and the Adolescent
Diagnostic Interview, which evaluates for Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition diagnoses of substance abuse/dependence and 8
types of psychiatric symptoms. We examined gender-specific associations of no/nonproblematic
substance use (NSU), SUP, and SUD with psychiatric symptom presence (any symptoms
within each type), score (symptom scores summed across all types), and number
of types (number of different symptom types endorsed). RESULTS: Of 538 adolescents
(68% female; mean +/- standard deviation age: 16.6 +/- 1.4 years), 66% were classified
with NSU, 18% with SUP, and 16% with SUD, and 80% reported having at least 1 type
of psychiatric symptom in the previous 12 months. Symptoms of anxiety were most
common (60% of both boys and girls), followed by symptoms of depression among
girls (51%) and symptoms of attention-deficit disorder (ADD) among boys (47%).
Compared with those with NSU, youths with SUP and those with SUD were more likely
to report symptom presence for several types of psychiatric symptoms. Girls with
SUP or SUD had increased odds of reporting symptoms of mania, ADD, and conduct
disorder; girls with SUD were at increased risk for symptoms of depression, eating
disorders, and hallucinations or delusions. Boys with SUP had increased odds of
ADD symptoms, whereas boys with SUD had increased odds of reporting hallucinations
or delusions. Boys with SUP or SUD had increased odds of reporting symptoms of
conduct disorder. Youths with SUP and SUD also had higher psychiatric symptom
scores and reported a wider range of psychiatric symptom types (number of types)
compared with youths with NSU. CONCLUSIONS: Like those with SUD, adolescents with
subdiagnostic SUP were at increased risk for experiencing a greater number of
psychiatric symptoms and a wider range of psychiatric symptom types than youths
with NSU. Specifically, adolescents with SUP are at increased risk for symptoms
of mood (girls) and disruptive behavior disorders (girls and boys). These findings
suggest the clinical importance of SUP and support the concept of a continuum
between subthreshold and diagnostic substance use among adolescents in primary
care. Identification of youths with SUP may allow for intervention before either
the substance use or any associated psychiatric problems progress to more severe
TE, Biederman J, Millstein RB, Wozniak J, Hahesy AL, Spencer TJ.
for substance use disorders in youths with child- and adolescent-onset bipolar
J Am Acad Child Adolesc Psychiatry 1999 Jun;38(6):680-5
"OBJECTIVE: Previous work in adults has suggested that early-onset bipolar
disorder (BPD) is associated with an elevated risk for substance use disorders
(SUD). To this end, the authors assessed the risk for SUD in child- versus adolescent-onset
BPD with attention to comorbid psychopathology. METHOD: All youths (aged 13-18
years) with available structured psychiatric interviews were studied systematically.
From clinic subjects (N = 333), 86 subjects with DSM-III-R BPD were identified.
To evaluate the risk for SUD and BPD while attending to developmental issues,
the authors stratified the BPD sample into those with child-onset BPD (< or
= 12 years of age, n = 50) and those with adolescent-onset BPD (13-18 years of
age, n = 36). RESULTS: In mid-adolescence, youths with adolescent-onset BPD were
at significantly increased risk for SUD relative to those with child-onset BPD
(39% versus 8%; p = .001). Compared with those with child-onset BPD, those with
adolescent-onset BPD had 8.8 times the risk for SUD (95% confidence interval =
2.2-34.7; chi 7(2) = 9.7, p = .002). The presence of conduct disorder or other
comorbid psychopathology within BPD did not account for the risk for SUD. CONCLUSIONS:
Adolescent-onset BPD is associated with a much higher risk for SUD than child-onset
BPD, which was not accounted for by conduct disorder or other comorbid psychopathology.
Youths with adolescent-onset BPD should be monitored and educated about SUD risk.
The identification and treatment of manic symptomatology may offer therapeutic
opportunities to decrease the risk for SUD in these high-risk youths." [Abstract]
KD, Steiner H, Ketter TA.
Psychiatric phenomenology of child and
adolescent bipolar offspring.
J Am Acad Child Adolesc Psychiatry
"OBJECTIVE: To establish prodromal signs of and
risk factors for childhood bipolar disorder (BD) by characterizing youths at high
risk for BD. METHOD: Structured diagnostic interviews were performed on 60 biological
offspring of at least one parent with BD. Demographics, family histories, and
parental history of childhood disruptive behavioral disorders were also assessed.
RESULTS: Fifty-one percent of bipolar offspring had a psychiatric disorder, most
commonly attention-deficit/hyperactivity disorder (ADHD), major depression or
dysthymia, and BD. BD in offspring tended to be associated with earlier parental
symptom onset when compared with offspring without a psychiatric diagnosis. Bipolar
parents with a history of childhood ADHD were more likely to have children with
BD, but not ADHD. Offspring with bilineal risk had increased severity of depressed
and irritable mood, lack of mood reactivity, and rejection sensitivity, while
severity of grandiosity, euphoric mood, and decreased need for sleep were not
preferentially associated with such offspring. CONCLUSIONS: Bipolar offspring
have high levels of psychopathology. Parental history of early-onset BD and/or
childhood ADHD may increase the risk that their offspring will develop BD. Prodromal
symptoms of childhood BD may include more subtle presentations of mood regulation
difficulties and less presence of classic manic symptoms." [Abstract]
GA, Loney J, Salisbury H, Volpe RJ.
Young referred boys with DICA-P
manic symptoms vs. two comparison groups.
J Affect Disord
"A total of 23 boys met DICA-P manic symptom and
clustering criteria in a diagnostic investigation of 233 outpatient boys between
ages 6 and 10. In this manic-symptom group, the most frequently endorsed of an
average of five manic symptoms were extreme mood changes, difficulty concentrating,
feeling too 'up' to sit still, and racing thoughts. Comparison groups were 23
non-manic boys seen next in the investigation and 23 non-manic boys matched to
the manic-symptom boys on symptoms of three comorbid disruptive disorders (ADHD,
ODD and CD). Manic-symptom boys differed significantly from next-seen boys, but
not from matched comorbid boys, in number of oppositional symptoms and pervasiveness
of problems. Manic-symptom boys differed significantly from next-seen boys on
six of eight mother-rated RCBCL factors. In contrast, manic-symptom and matched
comorbid boys did not differ on any of eight RCBCL factors, which suggests that
the RCBCL differences can be attributed to shared ADHD, ODD and/or CD. However,
manic-symptom and matched comorbid boys tended to differ on RCBCL Anxiety/Depression.
On the teacher-rated TRF, manic-symptom boys were rated higher than next-seen
boys on four internalizing factors, and higher than matched comorbid boys on two
of those factors, including Anxiety/Depression. Thus, manic symptomatology also
predicted substantial emotionality, which was not a controlled comorbidity. The
findings of this and other studies suggest that there is a mania dimension or
syndrome, which may be an indicator of true bipolar disorder--or simply a marker
for disruptive comorbidity, behavioral and emotional multimorbidity, or general
severity of psychopathology." [Abstract]
L, Hagino O, Weller E, Weller R.
Bipolarity in children.
Psychiatr Clin North Am 1999 Sep;22(3):629-48
"Childhood and adolescent
bipolar disorder have been less studied than adult onset bipolar illness. However,
case reports of mania in childhood can be found as early as the mid 19th century.
Historically, several factors have made the accurate diagnosis of bipolar disorder
in childhood difficult: clinical bias against the diagnosis of mania in children;
low base rate of disorder; symptom overlap between bipolar disorder and other
more prevalent childhood-onset psychiatric disorders; and developmental constraints
and variability in clinical presentation. The epidemiology of juvenile-onset bipolar
disorder remains an open topic for research. The disorder appears to increase
in prevalence with advancing age until young adulthood. Reported phenomenology
of bipolar disorder in children and adolescents indicates a highly variable presentation
with a developmental trend towards increased resemblance to the adult phenotype
with increasing age of onset. Diagnostic accuracy for the disorder is improved
by adherence to diagnostic and statistical manual of mental disorders (DSM) criteria
and may be aided by structured or semistructured diagnostic interviews. The course
of bipolar disorder in children and adolescents has also received limited systematic
study. However, research to date supports a clinical picture of a relapsing, recurrent
illness with substantial morbidity. Systematic studies of pharmacologic treatments
of acute mania in children and adolescents are limited in number and scope. Clinical
justification for the use of acute antimanic treatments such as lithium and valproic
acid is still based upon studies conducted in adults. There remains an immediate
and significant need for additional research into all aspects of juvenile-onset
bipolar disorder." [Abstract]
S, Schmitz M, Polanczyk G, Rohde LA.
Juvenile bipolar disorder in
Brazil: clinical and treatment findings.
2003 Jun 1;53(11):1043-9.
"BACKGROUND: Because few studies were conducted
to evaluate bipolar disorder in children and adolescents outside North America,
this investigation aims to describe clinical features, pattern of comorbidities,
and response to pharmacologic treatment in a sample of youths with bipolar disorder
(BD) from a pediatric psychopharmacology outpatient clinic in Brazil. METHODS:
We performed a retrospective chart review of all patients under age 15 with BD
diagnoses who were evaluated and treated in our clinic from 1998-2001. A comparison
sample of subjects with attention-deficit/hyperactivity disorder (ADHD) without
BD (n = 362) was also evaluated. RESULTS: The prevalence of juvenile BD in our
sample was 7.2% (36/500) (95% confidence interval = 5.2-9.9). Irritable mood was
detected in 91.7% of the bipolar patients. The main comorbidity found was ADHD
(58.3%). Children with BD had significantly higher rates of abnormally elevated
CBCL scores in the externalizing dimension, anxiety and depression, delinquent
behavior, and aggressive behavior scales than ADHD subjects (p <.05). Most
BD patients (78%) needed combination drug therapy to achieve symptomatic control.
CONCLUSIONS: Our results replicate clinical and treatment findings from U.S. investigations
in a different culture demonstrating that juvenile BD is not a rare disorder in
clinical samples." [Abstract]