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The study compared use of specialty outpatient mental services among children ages six and seven and children ages eight through 12 and investigated predictors of differences in the patterns of service use by age.Eligible children were first-time patients of clinics participating in the Longitudinal Assessment of Manic Symptoms who were between ages six and 12 and who were English speaking. Children who screened positive for symptoms of mania (N=1,124) were invited to participate, and families of 621 (55%) children consented. A matched sample of 86 children without a positive screen for mania also participated. Baseline interviews assessed sociodemographic characteristics of the child and family and the child's functioning, diagnoses, and use of services.Of the 707 children, 30% were younger, and 50% used multiple types of specialty outpatient services. Younger children were more likely to be male, have Medicaid insurance, and have two parents with mental health problems. Use of multiple types of services was related to study site, high depression scores, fewer minor health issues, and fewer stressful life events among younger children and with parental stress, primary diagnosis, poor functioning, and not living with both parents among older children. Younger children were much more likely than older children to have used services before age six.Younger children showed very early use of multiple types of services for mental health problems and a pattern of persistent impairment despite long-standing use of services. These data argue strongly for focusing on emotional and behavioral issues among young children.

IMPORTANCE: Pediatric disorders characterized by behavioral and emotional dysregulation pose diagnostic and treatment challenges because of high comorbidity, suggesting that they may be better conceptualized dimensionally rather than categorically. Identifying neuroimaging measures associated with behavioral and emotional dysregulation in youth may inform understanding of underlying dimensional vs disorder-specific pathophysiologic features. OBJECTIVE: To identify, in a large cohort of behaviorally and emotionally dysregulated youth, neuroimaging measures that (1) are associated with behavioral and emotional dysregulation pathologic dimensions (behavioral and emotional dysregulation measured with the Parent General Behavior Inventory 10-Item Mania Scale [PGBI-10M], mania, depression, and anxiety) or (2) differentiate diagnostic categories (bipolar spectrum disorders, attention-deficit/hyperactivity disorder, anxiety, and disruptive behavior disorders). DESIGN, SETTING, AND PARTICIPANTS: A multisite neuroimaging study was conducted from February 1, 2011, to April 15, 2012, at 3 academic medical centers: University Hospitals Case Medical Center, Cincinnati Children's Hospital Medical Center, and University of Pittsburgh Medical Center. Participants included a referred sample of behaviorally and emotionally dysregulated youth from the Longitudinal Assessment of Manic Symptoms (LAMS) study (n = 85) and healthy youth (n = 20). MAIN OUTCOMES AND MEASURES: Region-of-interest analyses examined relationships among prefrontal-ventral striatal reward circuitry during a reward paradigm (win, loss, and control conditions), symptom dimensions, and diagnostic categories. RESULTS: Regardless of diagnosis, higher PGBI-10M scores were associated with greater left middle prefrontal cortical activity (r = 0.28) and anxiety with greater right dorsal anterior cingulate cortical (r = 0.27) activity to win. The 20 highest (t = 2.75) and 20 lowest (t = 2.42) PGBI-10M-scoring youth showed significantly greater left middle prefrontal cortical activity to win compared with 20 healthy youth. Disruptive behavior disorders were associated with lower left ventrolateral prefrontal cortex activity to win (t = 2.68) (all P

The purpose of this study was to report the safety, tolerability, and serum micronutrient concentrations and their correlations with mood changes from an 8 week pilot feasibility study of a 36 ingredient multinutrient supplement, EMPowerplus (EMP+), for pediatric bipolar spectrum disorders (BPSD).Ten children ages 6-12 received EMP+ escalating from one to four capsules t.i.d., with four children increased to the maximum suggested dose, five capsules t.i.d. Outcome measures were micronutrient concentrations in serum and red blood cells, vital signs, body mass index (BMI), dietary intake (Food Frequency Questionnaire and 24 hour dietary recall interview), and mood and global functioning ratings.Seven children (70%) completed the study. Three (30%) terminated early for tolerability and compliance issues. Adverse effects were mild and transient, and chiefly consisted of initial insomnia or gastrointestinal (GI) upset. No differences occurred in BMI (p = 0.310) or waist-hip ratio (WHR; p = 0.674) pre- to postsupplementation. Four of the tested serum vitamin concentrations increased from pre- to postsupplementation: vitamin A-retinol, vitamin B6, vitamin E-α-tocopherol; and folate (all p0.05). The increase in serum 25-OH vitamin D approached significance (p = 0.063). No differences were found in dietary intake pre- to postsupplementation, suggesting that blood nutrient level increases were caused by EMP+.In this open prospective study, short-term use of EMP+ in children with BPSD appeared safe and well-tolerated, with a side effect profile preferable to first-line psychotropic drugs for pediatric bipolar spectrum disorders. A double-blind, randomized clinical trial is feasible, appears safe, and is warranted by open-label clinical outcomes and plausible mechanisms of action, combined with documentation of increased serum concentrations of specific micronutrients.

Mood disorders and suicide in youth represent major health concerns requiring effective intervention strategies. This paper briefly summarizes the literature on childhood mood disorders and discusses expressed emotion (EE) and the link between lowering EE and improved outcome for mood disordered individuals. Family psychoeducation is discussed as a means of reducing EE and similarities and differences between psychoeducation and other therapeutic interventions explored. The authors' adaptations that made psychoeducation developmentally appropriate for families of children and adolescents are reviewed. Psychoeducation for families of mood disordered youth is suggested as worthy of further clinical and empirical effort.

The prevalence of emotional and behavioral disorders in children and adolescents underscores the need for programs to educate and provide support for parents and caregivers. To foster learning, healing, and empowerment among parents and caregivers, the National Alliance for the Mentally Ill (NAMI) created the Hand–to–Hand Family Education Program. Goals of this eight–week class, taught by family members who are part of NAMI, are to provide members with information about the etiology and symptoms of childhood emotional, behavioral, and neurobiological disorders and their treatment, guide parents on being advocates in their children’s school and mental health services, and help parents increase levels of support and coping skills. To examine the effectiveness of Hand–to–Hand in reducing parental stress levels and increasing support for families of children with brain disorders, we collected data from members of four Hand–to–Hand groups. The following is a summary of our research findings.

Objective Pediatric bipolar disorder involves poor social functioning, but the neural mechanisms underlying these deficits are not well understood. Previous neuroimaging studies have found deficits in emotional face processing localized to emotional brain regions. However, few studies have examined dysfunction in other regions of the face processing circuit. This study assessed hypoactivation in key face processing regions of the brain in pediatric bipolar disorder. Method Youth with a bipolar spectrum diagnosis (n = 20) were matched to a nonbipolar clinical group (n = 20), with similar demographics and comorbid diagnoses, and a healthy control group (n = 20). Youth participated in a functional magnetic resonance imaging (fMRI) scanning which employed a task-irrelevant emotion processing design in which processing of facial emotions was not germane to task performance. Results Hypoactivation, isolated to the fusiform gyrus, was found when viewing animated, emerging facial expressions of happiness, sadness, fearfulness, and especially anger in pediatric bipolar participants relative to matched clinical and healthy control groups. Conclusions The results of the study imply that differences exist in visual regions of the brain's face processing system and are not solely isolated to emotional brain regions such as the amygdala. Findings are discussed in relation to facial emotion recognition and fusiform gyrus deficits previously reported in the autism literature. Behavioral interventions targeting attention to facial stimuli might be explored as possible treatments for bipolar disorder in youth.

Objective To explore the relationship between lithium dose and serum lithium level on the occurrence of untoward or toxic effects of lithium in the treatment of 20 hospitalized aggressive and/or mood-disordered children aged 4 through 6 years. Method Clinical and research records of 20 children treated with lithium according to an established inpatient protocol were reviewed. Side effects as reported by psychiatric staff were categorized by organ system affected and severity. Results During the initial 2 weeks of lithium treatment, 60% of the children manifested one or more types of side effects, most commonly central nervous system effects. Side effects were seen at doses of 25.6 to 52.1 mg/kg per day and at serum levels from 0.65 to 1.37 mEq/L. In general, adverse effects were associated with higher lithium doses and lithium levels and were most common during the first week of treatment. A potential interaction between concurrent infection and more severe side effects was seen. Conclusions Side effects occur frequently in children aged 6 years and younger during the initiation phase of lithium treatment; are related to higher milligram per kilogram doses, higher serum lithium levels, and phase of treatment; and may be related to concurrent medical illness.

Treatment guidelines recommend that psychotherapy be used in conjunction with pharmacotherapy in children with bipolar disorder. A well-established category of psychotherapy is family skill-building plus psychoeducation; 3 examples of this are family-focused treatment, psychoeducational psychotherapy, and child- and family-focused cognitive-behavioral therapy. These treatments share several common elements that are important in pediatric populations, including being family-based, providing psychoeducation on symptoms and their management, and training patients and families in emotion regulation, communication, and problem-solving skills. Clinicians may also wish to explore nutritional interventions; multinutrient complexes are experimental, and omega-3 fatty acid supplements are possibly efficacious. Nutritional interventions are particularly attractive in this patient population because of their favorable safety profile.

Bipolar disorder has not been well studied in prepubertal children, despite its potentially debilitating effects on growth and development. However, there have been case reports of mania in this age group dating back to Esquirol in the mid-19th century. Despite anecdotal case reports, explicit criteria to diagnose mania in children were not used until 1960. Since 1980 the DSM-III/DSM-III-R criteria have indicated adult criteria can be used to diagnose childhood mania, with some modifications to adjust for age differences. Bipolar disorder has not been frequently considered in the psychiatric differential diagnosis of children. However, if a diagnosis of mania is made, clinical rating scales can be used to rate the severity of manic symptoms and to monitor treatment. A manic child should be treated using a biopsychosocial approach. To date, lithium carbonate has been the most commonly used psychopharmacological treatment, but results have been variable. Additional research is needed, including double-blind, placebo-controlled studies to document the beneficial effects of mood-stabilizing medications. Also, diagnostic instruments should be refined to improve their utility. Finally, children at high risk for developing mania should be studied to identify predictors of bipolar disorder in children.

Dialectical behavior therapy (DBT) was originally developed for chronically suicidal adults with borderline personality disorder (BPD) and emotion dysregulation. Randomized controlled trials (RCTs) indicate DBT is associated with improvements in problem behaviors, including suicide ideation and behavior, non-suicidal self-injury (NSSI), attrition, and hospitalization. Positive outcomes with adults have prompted researchers to adapt DBT for adolescents. Given this interest in DBT for adolescents, it is important to review the theoretical rationale and the evidence base for this treatment and its adaptations. A solid theoretical foundation allows for adequate evaluation of content, structural, and developmental adaptations and provides a framework for understanding which symptoms or behaviors are expected to improve with treatment and why. We first summarize the adult DBT literature, including theory, treatment structure and content, and outcome research. Then, we review theoretical underpinnings, adaptations, and outcomes of DBT for adolescents. DBT has been adapted for adolescents with various psychiatric disorders (i.e., BPD, mood disorders, externalizing disorders, eating disorders, trichotillomania) and problem behaviors (i.e., suicide ideation and behavior, NSSI) across several settings (i.e., outpatient, day program, inpatient, residential, correctional facility). The rationale for using DBT with these adolescents rests in the common underlying dysfunction in emotion regulation among the aforementioned disorders and problem behaviors. Thus, the theoretical underpinnings of DBT suggest that this treatment is likely to be beneficial for adolescents with a broad array of emotion regulation difficulties, particularly underregulation of emotion resulting in behavioral excess. Results from open and quasi-experimental adolescent studies are promising; however, RCTs are sorely needed.

To determine the contribution of parent-reported manic symptoms, family history, stressful life events, and family environment in predicting diagnosis of bipolar spectrum disorders (BPSD) in youth presenting to an outpatient psychiatric clinic.A total of 707 6- to 12-year-old children [621 with elevated symptoms of mania (ESM+) based on screening via the Parent General Behavior Inventory 10-item Mania Scale (PGBI-10M) and 86 without ESM (ESM-)] received a comprehensive assessment.Of the 629 with complete data, 24% (n = 148) had BPSD. Compared to those without BPSD (n = 481), children with BPSD: were older (Cohen's d = 0.44) and more likely to be female (Cohen's d = 0.26); had higher parent-endorsed manic symptom scores at screening (Cohen's d = 0.36) and baseline (Cohen's d = 0.76), more biological parents with a history of manic symptoms (Cohen's d = 0.48), and greater parenting stress (Cohen's d = 0.19). Discriminating variables, in order, were: baseline PGBI-10M scores, biological parent history of mania, parenting stress, and screening PGBI-10M scores. Absence of all these factors reduced risk of BPSD from 24% to 2%. History of parental manic symptoms remains a robust predictor of BPSD in youth seeking outpatient care, even after accounting for parent report of manic symptoms in the child at screening. However, the risk factors identified as associated with BPSD, together had limited value in accurately identifying individual participants with BPSD, highlighting the need for careful clinical assessment.

Current psychotropic medications for childhood bipolar spectrum disorders (BPSD) are associated with significant adverse events. As nutrients play an important role in physical and mental health, they may be useful in treating mood disorders with few side-effects. This open-label study explored the feasibility of testing therapeutic effects of a multinutrient supplement, EMPowerplus™ (EMP+), for pediatric BPSD.EMP+ was started at one capsule t.i.d. and escalated to a goal of four capsules t.i.d., which eight children attained. Four (4) of these increased to the maximum dose, five capsules t.i.d. Mood symptoms were assessed seven times over 8 weeks.Ten (10) children, age 6-12 with BPSD, were enrolled in 6.5 months. Seven (7) participants completed the full trial. Three (3) dropped out due to palatability and/or adherence issues.Mean medication adherence was 91%. With one-tailed nonparametric Fisher's randomization tests, intent-to-treat analyses demonstrated a 37% decrease in depression scores (p0.06) and a 45% decrease in mania scores (p0.01) from the start of treatment through final visit, suggesting improvement and possible treatment response. Study completers demonstrated significant decreasing trends in both depression and mania scores from baseline to final visit (p0.05). Side-effects were minor and transient, mostly temporary gastric discomfort.Future randomized, placebo-controlled trials of EMP+ are warranted and feasible.

Despite efforts that have been made to develop and evaluate psychosocial interventions for youth with bipolar spectrum disorders (BPSDs), there has been limited evidence regarding treatment delivery and consumer experiences in clinical settings. Two parallel web-based surveys were conducted to assess clinicians' experiences with providing psychosocial treatments to youth with BPSD, and caregivers' experiences with accessing and receiving care for their youth with BSPD. Clinicians who were members of the American Psychological Association's Division 53 listserv were invited to report on (1) their training in and knowledge of BPSD among youth; (2) types of treatments they had provided and their perceived effectiveness; (3) treatment-related challenges; and (4) further training opportunities or resources they desire. Caregivers who were members of the Balanced Mind Foundation listserv were invited to participate in a separate survey. They were asked to report on both negative and positive experiences they had in their most recent experience with accessing and receiving psychosocial treatment for their youth with BPSD. Overall, the majority of clinician respondents reported receiving training in providing psychosocial treatments to youth with BPSD, though most reported desiring further training and greater access to resources (e.g., treatment manuals, workshops, case consultation). Caregivers indicated overall positive experiences with psychosocial treatments for their youth with BPSD. Positive experiences included those associated with nonspecific factors of therapy, and negative experiences included content-related factors and barriers to accessing treatments. Implications for enhancing treatment delivery and overall experience of psychosocial interventions among youth with BPSD are discussed.

This study examined the role of comorbid anxiety in treatment outcome for children with mood disorders (N = 165; age 8–11) participating in Multi-Family Psychoeducational Psychotherapy (MF-PEP). Assessments occurred at baseline, 6, 12, and 18 months for two randomly assigned groups: immediate treatment and 1-year wait-list. Most children (69%) had comorbid anxiety disorders. Baseline comorbid anxiety, as reported on the Children’s Interview for Psychiatric Syndromes (ChIPS), was associated with higher Children’s Depression Rating Scale- Revised (CDRS-R) scores but not Young Mania Rating Scale (YMRS) scores. Higher levels of anxiety symptoms were associated with lower Children’s Global Assessment Scale (C-GAS) scores. Participation in MF-PEP did not significantly reduce anxiety symptoms (p = 0.62). However, presence of comorbid anxiety did not impede reduction in depressive (CDRS-R, p = 0.74) or manic (YMRS scores, p = 0.94) symptoms following MF-PEP. More baseline anxiety symptoms were associated with greater improvement in C-GAS scores post-treatment (p = 0.02). Implications are discussed.

Transgenerational association of bipolar spectrum disorder (BPSD) and attention deficit/hyperactivity disorder (ADHD) has been reported, but inconclusively.Children ages 6-12 were systematically recruited at first outpatient visit at 9 clinics at four universities and reliably diagnosed; 621 had elevated symptoms of mania (12 on the Parent General Behavior Inventory 10-Item Mania Scale); 86 had scores below 12. We analyzed baseline data to test a familial association hypothesis: compared to children with neither BPSD nor ADHD, those with either BPSD or ADHD would have parents with higher rates of both bipolar and ADHD symptoms, and parents of comorbid children would have even higher rates of both.Of 707 children, 421 had ADHD without BPSD, 45 BPSD without ADHD, 117 comorbid ADHD+BPSD, and 124 neither. The rate of parental manic symptoms was similar for the comorbid and BPSD-alone groups, significantly greater than for ADHD alone and "neither" groups, which had similar rates. ADHD symptoms in parents of children with BPSD alone were significantly less frequent than in parents of children with ADHD (alone or comorbid), and no greater than for children with neither diagnosis. Family history of manic symptoms, but not ADHD symptoms, was associated with parent-rated child manic-symptom severity over and above child diagnosis.The sample was not epidemiologic, parent symptoms were based on family history questions, and alpha was 0.05 despite multiple tests.These results do not support familial linkage of BPSD and ADHD; they are compatible with heritability of each disorder separately with coincidental overlap.

The authors examined the association of demographic and clinical characteristics, family history, and type of treatment among children receiving outpatient mental health services and parents' perception of treatment benefit. They also examined whether perceived benefit was related to continued use of services at six-month follow-up.Parents of children age six to 12 years who were first-time patients at one of nine clinics participating in the Longitudinal Assessment of Manic Symptoms (LAMS) study completed the Parent General Behavior Inventory Ten-Item Mania Scale. Parents of children with scores of 12 or higher (N=1,124) were invited to participate in a follow-up study, and 621 agreed. During baseline assessment after the first outpatient visit and at six-month follow-up, the parents were asked about children's sociodemographic and diagnostic characteristics and use of services and asked to rate how much their children had benefited from the most recent outpatient treatment.Data were available for 573 children. At baseline, parents of 167 (29%) children reported that the treatment provided a lot of benefit, and perceived benefit was related to receiving medication (with or without therapy) versus just therapy, higher scores on functioning, LAMS site, no history of comorbid diagnoses, living with both biological parents, and having no parents or siblings with a prior hospitalization for a psychiatric illness. At six-month follow-up, perceived benefit was related to continued use of services (p.001).Medication with or without therapy was perceived as more beneficial than therapy alone. Perceived benefit was strongly related to continued use of treatment.

Background This study examined depressive symptoms in bereaved children and adolescents two months after the death of a parent. Methods Participants were 325 children and adolescents bereaved of a parent approximately two months prior to the study. They were compared to 129 non-bereaved community controls and 110 non-bereaved depressed controls. Participants and their parents were interviewed regarding the child's depressive symptoms. Possible moderating factors for depression in bereaved children were examined. Results 25% of the bereaved participants experienced a major depressive episode (MDE) compared to 1% of the community controls. An additional 24% of the bereaved participants experienced a sub-syndromal depressive episode, defined as 3 or 4 depressive symptoms, compared to 4% of the community controls. Factors correlated with occurrence of MDE in the bereaved children in exploratory analyses were (1) history of MDE in the child and (2) history of alcoholism in a parent. Guilt/worthlessness, psychomotor disturbance, and low energy in the context of an MDE predicted membership in the depressed control group over the bereaved group. Limitations The relationship between an MDE in the bereaved child and parent history of alcoholism is exploratory, as the p-value for this correlation was greater than the α adjusted for multiple comparisons. The bereaved child's history of MDE was based on the child's and parent's memories of depressive symptoms. Conclusions The death of a parent is a risk factor for depressive symptoms and depressive episodes in children and adolescents two months after the death.

Bipolar Spectrum Disorders (BPSDs; Bipolar I and II, Cyclothymic Disorder, and Bipolar not otherwise specified (NOS)) are chronic, debilitating illnesses with considerable controversy surrounding their pediatric presentation.1 Over half (60%) of adults with bipolar disorder experience their first symptoms during adolescence.2,3 Nearly one-third (30%) experience symptoms prior to age 13.2,3 In clinical settings, children are increasingly likely to be given a bipolar diagnosis.4–7 Although controversy remains about the nature of bipolar spectrum presentations in youth,8 both “classic” and other spectrum presentations (BP-II, BP-NOS, cyclothymic disorder) are often associated with substantial suffering.9 Increased prevalence in clinical settings,10 combined with poor long-term outcomes, make accurate and early diagnosis of BPSD an important challenge with considerable public health significance. The few available studies examining prodromal symptoms for BPSD suggest that symptoms of mania may be indicative of early stages of illness,11–14 although many studies examining early symptoms concentrate on children of parents with BPSD,15–18 and few have used prospective designs.19–21 Growing evidence indicates a large number of children receiving psychiatric care present with elevated symptoms of mania (ESM).22–24 A substantial proportion of youth with ESM suffer from considerable dysfunction, although many do not meet strict DSM criteria for BPSD.24–27 Previous papers have described the participant characteristics28 and study design29 of the NIMH-funded Longitudinal Assessment of Manic Symptoms (LAMS) study. This article extends previous studies by describing diagnostic differences between youth with parent-reported manic symptoms that persist over two assessment points (Persistent ESM+) versus youth with manic symptoms that remit (Remitted ESM+) or are consistently low across two time points (Persistent ESM−). It was hypothesized that individuals with Persistent ESM+ would have higher rates of BPSD diagnoses than other youth. In this study, ESM is conceptualized as a phenotype that when positive and persistent (Persistent ESM+), is related to and potentially predictive of current or future BPSD diagnosis, but is not redundant with BPSD. This study’s secondary aim was to evaluate clinical utility of tracking manic symptoms over two time points in determining the presence of pediatric BPSD. Parent reports on brief rating scales have been particularly powerful at reducing the tendency to over-diagnose bipolar disorder.10,30 We expected that including information from two assessment time points would further increase the accuracy of predicting BPSD.

Arnold LE, Demeter C, Mount K, Frazier TW, Youngstrom EA, Fristad M, Birmaher B, Findling RL, Horwitz SM, Kowatch R, Axelson DA. Pediatric bipolar spectrum disorder and ADHD: comparison and comorbidity in the LAMS clinical sample. Bipolar Disord 2011: 13: 509–521. © 2011 The Authors. Journal compilation © 2011 John Wiley & Sons A/S. Objective: To compare attention-deficit hyperactivity disorder (ADHD), bipolar spectrum disorders (BPSDs), and comorbidity in the Longitudinal Assessment of Manic Symptoms (LAMS) study. Methods: Children ages 6–12 were recruited at first visit to clinics associated with four universities. A BPSD diagnosis required that the patient exhibit episodes. Four hypotheses were tested: (i) children with BPSD + ADHD would have a younger age of mood symptom onset than those with BPSD but no ADHD; (ii) children with BPSD + ADHD would have more severe ADHD and BPSD symptoms than those with only one disorder; (iii) global functioning would be more impaired in children with ADHD + BPSD than in children with either diagnosis alone; and (iv) the ADHD + BPSD group would have more additional diagnoses. Results: Of 707 children, 421 had ADHD alone, 45 had BPSD alone, 117 had both ADHD and BPSD, and 124 had neither. Comorbidity (16.5%) was slightly less than expected by chance (17.5%). Age of mood symptom onset was not different between the BPSD + ADHD group and the BPSD-alone group. Symptom severity increased and global functioning decreased with comorbidity. Comorbidity with other disorders was highest for the ADHD + BPSD group, but higher for the ADHD-alone than the BPSD-alone group. Children with BPSD were four times as likely to be hospitalized (22%) as children with ADHD alone. Conclusions: The high rate of BPSD in ADHD reported by some authors may be better explained as a high rate of both disorders in child outpatient settings rather than ADHD being a risk factor for BPSD. Co-occurrence of the two disorders is associated with poorer global functioning, greater symptom severity, and more additional comorbidity than for either single disorder.

This study describes the suicidal behavior of hospitalized depressed children and assesses its relationship to psychopathology and suicidal behavior in their parents. Subjects were 58 consecutively hospitalized prepubertal children with a primary diagnosis of major depressive disorder (MDD), and 58 age- and gender-matched children hospitalized for psychiatric diagnoses other than a mood disorder. Clinical interviews and structured diagnostic instruments were reviewed to determine the children's suicidal behavior and their parents' history of psychopathology. Suicidal ideation, suicidal intent, suicidal plans, and suicide attempts were more frequent in MDD children compared to nondepressed children. When MDD and control samples were stratified as to presence of suicidal behavior in the child, psychopathology was high in parents from all subgroups. Intensity of suicidal behavior in the depressed and non-depressed children was not associated with an altered pattern of psychopathology in their parents. Hospitalized MDD children had increased suicidal behavior compared to inpatient psychiatric control children. However, suicidal behavior in the children was not associated with increased psychopathology or an altered pattern of psychopathology in their parents.

This study compared clinical rating scales and self-report scales from the McMaster and Circumplex models of family functioning. Forty-one families were given self-report measures, while clinicians assessed the families using clinical rating scales. There are three main findings: (a) The McMaster instruments have superior sensitivity (i.e., ability to correctly identify clinical families based on instrument scores); (b) there is greater correspondence between clinical rating scales and family member self-report inventories on the McMaster instruments; (c) there is lack of support for the curvilinear model of pathology suggested by the Circumplex model, as evidenced by unequal and linear distribution of scores on the Circumplex dimensions.

To assess rates of conversion to bipolar spectrum disorder (BPSD) and risk factors associated with conversion in children with depressive spectrum disorders (DSD) and transient manic symptoms (TMS) over 18 months. TMS are manic-like symptoms of insufficient duration or number to warrant a diagnosis of BPSD.Participants were 165 children (mean = 9.9 years, SD = 1.3) with mood disorders from the Multi-Family Psychoeducational Psychotherapy (MF-PEP) treatment study: 37 with DSD+TMS, 13 with DSD, and 115 with BPSD. All were assessed with standardized instruments on four occasions over 18 months, with half receiving MF-PEP after their baseline assessment and half receiving MF-PEP after a one-year wait-list condition.At baseline, the Children's Global Assessment Scale scores did not differ significantly between the DSD+TMS, DSD, and BPSD groups. Conversion rates to BPSD were significantly higher for the DSD+TMS group (48.0%) compared to the DSD group (12.5%). Conversion was significantly more frequent for participants in the one-year wait-list control group (60%) compared to the immediate treatment group (16%). Clinical presentation, family environment, and family history did not differ significantly between the small subset of DSD+TMS participants who did convert to BPSD at follow-up and those who did not convert. Baseline functional impairment was greater for the converted group than the non-converted group.Transient manic symptoms are a risk factor for eventual conversion to BPSD; psychoeducational psychotherapy may be protective. As this exploratory study had a small sample size and did not correct for multiple comparisons, additional studies with larger sample sizes are needed.

To describe the design of a longitudinal study of youth with elevated symptoms of mania (ESM), as well as the prevalence and correlates of manic symptoms. Bipolar disorder in youth is serious and is surrounded by controversy about its phenomenology, course, and treatment. Yet, there are no longitudinal studies of youth selected only for ESM, the phenomenological hallmark. The study's objective is to document the rate and sociodemographic correlates of ESM in children attending outpatient psychiatric clinics.Parents of 3,329 children aged 6-12 years visiting 10 outpatient clinics were asked to complete the Parent General Behavior Inventory 10-Item Mania Scale (PGBI-10M). Children with PGBI-10M scores ≥ 12 (ESM positive-screen [ESM+]) and a matched sample of ESM screen-negative (ESM-) children were invited to enroll in the longitudinal study. The sample was accrued from November 14, 2005, to November 28, 2008.Most of the children whose parents filled out the PGBI-10M (N = 2,622, 78.8%) participated in the study. Nonparticipants were slightly younger (mean age = 9.1 years [SD = 2.0 years] versus 9.4 years [SD = 2.0 years] for participants; t3327 = 4.42, P.001). Nearly half of the participants (43%) were ESM+; these were more likely to be Latino (4.2% versus 2.5% for ESM-; χ(2)1 = 5.45, P = .02), younger (mean age = 9.3 years [SD = 2.0 years] versus 9.6 years [SD = 1.9 years] for ESM-; t2620 = 3.8, P.001), and insured by Medicaid (48.4% versus 35.4% for ESM-; χ(2)1 = 45.00, P.001). There were no sociodemographic differences between those who did versus did not agree to enroll in the longitudinal portion (yes to enrollment: n = 621, 55.2%; no to enrollment: n = 503, 44.8%). Four items best discriminated ESM+ children from ESM- children. Three of the 4 items were not the most commonly endorsed items, but all were indicative of behavioral extremes.Data suggest that ESM+ is not rare in 6- to 12-year-olds. Children who are ESM+ show behavioral extremes, including rapid mood shifts, compared to ESM- children.

This article first reviews the history of diagnosing bipolar disorder in children. Next, phenomenology, comorbidity, premorbid functioning, and course of bipolar disorder in children and adolescents are reviewed. Relevant adult studies are summarized as well. Treatment of bipolar disorder in children is reviewed, and, finally, factors associated with bipolar disorder are delineated.

Childhood mood disorders lack sufficient evidence-based treatments. While psychosocial treatments are recommended for both childhood depression and bipolar disorder, empirical support is scarce.To determine whether adjunctive multifamily psychoeducational psychotherapy would improve outcome for children aged 8 to 12 years with depression or bipolar disorder.One hundred sixty-five children were studied in a randomized controlled trial of multifamily psychoeducational psychotherapy plus treatment as usual (n = 78) compared with a wait-list control (WLC) condition plus treatment as usual (n = 87). Assessments occurred at baseline and at 6, 12, and 18 months. Intervention occurred between baseline and 6 months for the immediate treatment group and between 12 and 18 months for the WLC group.University medical center.Children were recruited from mental health and physical health care providers, media contacts, and word of mouth. All had a major mood disorder (major depressive disorder or dysthymic disorder, 30%; bipolar disorder type I, type II, or not otherwise specified, 70%). Intervention Children and 1 or more parents participated in eight 90-minute multifamily psychoeducational psychotherapy sessions. Parent and child groups met separately but began and ended sessions together.The Mood Severity Index (MSI) combines Mania Rating Scale and Children's Depression Rating Scale-Revised scores.Multifamily psychoeducational psychotherapy plus treatment as usual was associated with lower MSI scores at follow-up in intent-to-treat analyses compared with WLC plus treatment as usual (MSI: chi(2)(1) = 4.55; P = .03). The WLC group showed a similar decrease in MSI scores 1 year later, when also following their treatment (MSI decrease = 3.24 units per 6 months in the immediate treatment group and 3.50 units per 6 months in the WLC group).Brief, adjunctive psychoeducational group psychotherapy is associated with improved outcome for children aged 8 to 12 years with major mood disorders. Trial Registration clinicaltrials.gov Identifier: NCT00050557.

This study investigated the impact of psychoeducation on service utilization and mood symptom severity in children with mood disorders. Parents' knowledge of mood disorders, beliefs about treatment, and perceptions of children's need for treatment were hypothesized to mediate the relationship between psychoeducation and service utilization and between psychoeducation and mood symptom severity. Linear mixed effects modeling and joint significance test for mediation were used in secondary data analyses of the multifamily psychoeducation group (MFPG) study, a randomized controlled trial of 165 children ages 8 to 12 years with mood disorders. A majority of those sampled were male (73%) and White, non-Hispanic (90%), and the median range of family income was $40,000-$59,000. Participation in MFPG significantly improved quality of services utilized, mediated by parents' beliefs about treatment. Participation in MFPG also significantly improved severity of child's mood symptoms, mediated by quality of services utilized. MFPG appears to be a psychoeducational intervention that helps parents to become better consumers of the mental health system who access higher quality services. Children's symptom severity decreases as a result.

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

A parent's version of the Children's Depression Inventory (CDI-P) was compared with the Children's Depression Inventory (CDI-C). Subjects were 79 depressed children, 49 psychiatric controls, and 19 normal controls and their parents. CDI-P and CDI-C scores differentiated depressed children and psychiatric controls from normal controls (p < 0.0001). CDI-P scores did not differentiate depressed children from psychiatric controls. CDI-P scores were significantly higher than CDI-C scores among depressed and psychiatric controls (p < 0.02). The CDI-P and CDI-C appeared to be useful in assessing depressive symptoms in children but were less helpful in diagnosing depression.

Bipolar disorder (BPD) is increasingly diagnosed in youth in both outpatient and inpatient settings. Research on BPD in youth has also increased dramatically; this paper summarizes issues of clinical relevance in primary care, advancements in the last year, and areas in which more research is needed.Key issues and new developments are summarized in the following areas such as epidemiology and relevance, assessment and differential diagnosis, patient and family decision support, shared decision making and triage, treatment, and monitoring and collaboration with mental health professionals. Recent practice guidelines have important implications for diagnosis and treatment.Early-onset BPD appears to have a more severe course and more comorbidity than later life onset, as well as longer delays in treatment seeking. Affected children show differences in cognitive functioning and neuroanatomy compared with the general population. Assessment of BPD in children needs to be comprehensive and longitudinal, as diagnosis remains a debated topic. Medications are a primary part of treatment, but more double-blind, placebo-controlled trials are needed. Psychosocial adjunctive treatment is important. Children with a family history of BPD are at risk for impaired functioning and psychopathology; high-risk studies will increase our understanding of the onset and course of BPD.

Few controlled trials have examined psychotropic medications in children with mood disorders. Multiple medications are often prescribed for these children, who frequently suffer from several comorbid conditions. However, this polypharmacy has been infrequently studied and may lead to adverse drug-drug interactions. Multi-Family Psychoeducation Groups (MFPGs) are an 8-session, manual-driven treatment for children with mood disorders, designed as an adjunct to current medications and psychotherapy. In part, MFPG teaches parents and children to be better consumers of mental health care, including medications. This study examined the effect of MFPG on medications taken by 165 children, ages 8-11, with mood disorders. The authors hypothesized that MFPG would not affect the mean number of medications taken but that the variance in number of medications would decrease from pre- to posttreatment (i.e., the number of medications prescribed for any given child should become more closely distributed around the sample mean). Approximately 70% of participants were diagnosed with bipolar spectrum disorders, and 30% were diagnosed with depressive spectrum disorders. Most had both comorbid behavioral (97%) and anxiety (69%) disorders. Information regarding medications was gathered 4 times: at baseline, 6, 12, and 18 months. Approximately half (n=78) of the participants were randomized into immediate treatment, and half (n=87) were randomized into a 1-year wait-list condition. All were encouraged to continue treatment as usual throughout the study. As hypothesized, no significant pre- to posttreatment differences were found between groups for the mean number of current medications, but variance declined significantly from pre- to posttreatment. Implications and future research goals are discussed.