Mary A. Fristad

Treatment Guidelines for Children and Adolescents With Bipolar Disorder

Clinicians who treat children and adolescents with bipolar disorder desperately need current treatment guidelines. These guidelines were developed by expert consensus and a review of the extant literature about the diagnosis and treatment of pediatric bipolar disorders. The four sections of these guidelines include diagnosis, comorbidity, acute treatment, and maintenance treatment. These guidelines are not intended to serve as an absolute standard of medical or psychological care but rather to serve as clinically useful guidelines for evaluation and treatment that can be used in the care of children and adolescents with bipolar disorder. These guidelines are subject to change as our evidence base increases and practice patterns evolve.

The Mania Rating Scale: can it be used in children? A preliminary report.

The Mania Rating Scale (MRS) was evaluated for use in prepubertal children. Eleven manic and 11 matched controls with attention-deficit hyperactivity disorder were examined. MRS scores were significantly higher in manic versus ADHD children (p less than 0.0001), while scores on hyperactivity rating scales (Conners-Parent and Teacher Forms) did not differ between groups. Most individual MRS item scores differed significantly between groups (p less than 0.05). MRS scores correlated significantly with severity of mania (Clinical Global Impression--Mania, r = 0.84; p less than 0.0001). Age, race, and sex were not correlated with MRS scores. The MRS may be useful in differentiating mania from ADHD and determining the severity of mania in prepubertal children.

Impact of Multifamily Psychoeducational Psychotherapy in Treating Children Aged 8 to 12 Years With Mood Disorders

CONTEXT Childhood mood disorders lack sufficient evidence-based treatments. While psychosocial treatments are recommended for both childhood depression and bipolar disorder, empirical support is scarce. OBJECTIVE To determine whether adjunctive multifamily psychoeducational psychotherapy would improve outcome for children aged 8 to 12 years with depression or bipolar disorder. DESIGN 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. SETTING University medical center. PARTICIPANTS 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. MAIN OUTCOME MEASURES The Mood Severity Index (MSI) combines Mania Rating Scale and Childrens Depression Rating Scale-Revised scores. RESULTS 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). CONCLUSION 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.

Bipolar Disorder in Children Misdiagnosis, Underdiagnosis, and Future Directions

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.

Family psychoeducation: an adjunctive intervention for children with bipolar disorder

Childhood onset bipolar disorder is associated with significant morbidity and mortality, yet effective treatment strategies have remained underdeveloped and understudied. While some headway is being made vis-a-vis pharmacologic treatments, empirical efforts have not focused on adjunctive psychosocial interventions for childhood bipolar disorder. In this review, we discuss psychoeducation, delivered via workshops, multifamily psychoeducation groups, or individual-family psychoeducation, as an adjunct to the ongoing pharmacotherapy, psychotherapy, and school-based interventions for children with bipolar disorder. We review the theoretical rationale for psychoeducation, including expressed emotion and caregiver concordance; summarize findings in the adult literature; and then describe our development and testing of psychoeducational interventions for mood-impaired children. Data from three pilot studies are reviewed, and progress on two studies currently underway is presented. We conclude with current limitations of psychoeducation and recommendations for future study to develop psychoeducation as an empirically supported adjunctive intervention for children with bipolar disorder.

Psychoeducational treatment for school-aged children with bipolar disorder.

Bipolar disorder (BPD) has received increasing attention from public and professional sources. Although pharmacologic treatments are considered the sine qua non in the treatment of youth with BPD, psychosocial interventions are critical to assist the child and family cope with symptoms that carry with them significant morbidity and mortality. Treatments developed to date are few in number; all are psychoeducationally based, using cognitive-behavioral and family systems interventions within a biopsychosocial framework. This paper reviews possible mediators of outcome, including caregiver concordance, childrens social skills, hopelessness, and family stress. The author has developed two family-based psychoeducational interventions for the treatment of youth with BPD: multifamily psychoeducation groups (MFPG) and individual family psychoeducation (IFP). These treatments are both described and the results from a previously published randomized clinical trial (RCT) of MFPG are summarized. Then, new findings from an RCT of IFP are presented, along with preliminary pilot data from an expanded version of IFP. The paper concludes with recommendations for future research.

Examining the Proposed Disruptive Mood Dysregulation Disorder Diagnosis in Children in the Longitudinal Assessment of Manic Symptoms Study

OBJECTIVE To examine the proposed disruptive mood dysregulation disorder (DMDD) diagnosis in a child psychiatric outpatient population. Evaluation of DMDD included 4 domains: clinical phenomenology, delimitation from other diagnoses, longitudinal stability, and association with parental psychiatric disorders. METHOD Data were obtained from 706 children aged 6-12 years who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study (sample was accrued from November 2005 to November 2008). DSM-IV criteria were used, and assessments, which included diagnostic, symptomatic, and functional measures, were performed at intake and at 12 and 24 months of follow-up. For the current post hoc analyses, a retrospective diagnosis of DMDD was constructed using items from the K-SADS-PL-W, a version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, which resulted in criteria closely matching the proposed DSM-5 criteria for DMDD. RESULTS At intake, 26% of participants met the operational DMDD criteria. DMDD+ vs DMDD- participants had higher rates of oppositional defiant disorder (relative risk [RR] = 3.9, P < .0001) and conduct disorder (RR = 4.5, P < .0001). On multivariate analysis, DMDD+ participants had higher rates of and more severe symptoms of oppositional defiant disorder (rate and symptom severity P values < .0001) and conduct disorder (rate, P < .0001; symptom severity, P = .01), but did not differ in the rates of mood, anxiety, or attention-deficit/hyperactivity disorders or in severity of inattentive, hyperactive, manic, depressive, or anxiety symptoms. Most of the participants with oppositional defiant disorder (58%) or conduct disorder (61%) met DMDD criteria, but those who were DMDD+ vs DMDD- did not differ in diagnostic comorbidity, symptom severity, or functional impairment. Over 2-year follow-up, 40% of the LAMS sample met DMDD criteria at least once, but 52% of these participants met criteria at only 1 assessment. DMDD was not associated with new onset of mood or anxiety disorders or with parental psychiatric history. CONCLUSIONS In this clinical sample, DMDD could not be delimited from oppositional defiant disorder and conduct disorder, had limited diagnostic stability, and was not associated with current, future-onset, or parental history of mood or anxiety disorders. These findings raise concerns about the diagnostic utility of DMDD in clinical populations.

Characteristics of children with elevated symptoms of mania: The Longitudinal Assessment of Manic Symptoms (LAMS) study

OBJECTIVE The aim of the Longitudinal Assessment of Manic Symptoms (LAMS) study is to examine differences in psychiatric symptomatology, diagnoses, demographics, functioning, and psychotropic medication exposure in children with elevated symptoms of mania (ESM) compared to youth without ESM. This article describes the initial demographic information, diagnostic and symptom prevalence, and medication exposure for the LAMS cohort that will be followed longitudinally. METHOD Guardians of consecutively ascertained new outpatients 6 to 12 years of age presenting for treatment at one of 10 university-affiliated mental health centers were asked to complete the Parent General Behavior Inventory-10-Item Mania Scale (PGBI-10M). Patients with scores ≥ 12 on the PGBI-10M (ESM+) and a matched sample of patients who screened negative (ESM-) were invited to participate. Patients were enrolled from December 13, 2005, to December 18, 2008. RESULTS 707 children (621 ESM+, 86 ESM-; mean [SD] age = 9.4 [2.0] years) were evaluated. The ESM+ group, compared to the ESM- group, more frequently met DSM-IV criteria for a mood disorder (P < .001), bipolar spectrum disorders (BPSD; P < .001), and disruptive behavior disorders (P < .01). Furthermore, they showed poorer overall functioning and more severe manic, depressive, attention-deficit/hyperactivity, disruptive behavioral, and anxiety symptoms. Nevertheless, rates of BPSD were relatively low in the ESM+ group (25%), with almost half of these BPSD patients (12.1% of ESM+ patients) meeting DSM-IV criteria for bipolar disorder not otherwise specified. ESM+ children with BPSD had significantly more of the following: current prescriptions for antipsychotics, mood stabilizers, and anticonvulsants (P < .001 for each); psychiatric hospitalizations (P < .001); and biological parents with elevated mood (P = .001 for mothers, P < .013 for fathers). ESM+ children with BPSD were also lower functioning compared to ESM+ children without BPSD. CONCLUSIONS Although ESM+ was associated with higher rates of BPSD than ESM-, 75% of ESM+ children did not meet criteria for BPSD. Results suggest that longitudinal assessment is needed to examine which factors are associated with diagnostic evolution to BPSD in children with elevated symptoms of mania.

Behavior Disorders in Extremely Preterm/Extremely Low Birth Weight Children in Kindergarten

Objective: To examine the prevalence of behavior disorders in a 2001–2003 birth cohort of extremely preterm/extremely low birth weight (EPT/ELBW, <28 weeks gestational age or <1000 g) children in kindergarten. Method: We compared 148 EPT/ELBW children with 111 term-born normal birth weight classmate controls on reports of psychiatric symptoms obtained from parent interview (Childrens Interview for Psychiatric Syndromes-Parent Form [P-ChIPS]), parent and teacher ratings of behavior (Child Behavior Checklist, Teachers Report Form, and Behavior Rating Inventory of Executive Function), and teacher ratings of social functioning (School Social Behavior Scales, second edition). Associations of behavior disorders with global cognitive ability and tests of executive function were also examined within the EPT/ELBW group. Results: Rates of attention-deficit/hyperactivity disorder combined on psychiatric interview were about twice as high for the EPT/ELBW group than for the normal birth weight group, odds ratio (95% confidence interval) = 2.50 (1.34, 4.68), p = .004. The EPT/ELBW group also had much higher rates of teacher-identified disorders in attention, behavior self-regulation, and social functioning, with odds ratios (95% confidence intervals) ranging from 3.35 (1.64, 6.83) to 18.03 (4.12, 78.94), all p values <.01. Attention-deficit/hyperactivity disorder and impaired behavior self-regulation were associated with deficits on tests of executive function but not with global cognitive impairment. Conclusions: The findings document increased rates of disorders in attention, behavior self-regulation, and socialization in EPT/ELBW children and suggest that deficits on tests of executive function are associated with some of these disorders. Early identification and intervention for these disorders are needed to promote early adjustment to school and facilitate learning progress.

Multi-Family Psychoeducation Groups For Childhood Mood Disorders: A Program Description And Preliminary Efficacy Data

Existing literature suggests family-based psychoeducation effectively reduces relapse rates, thereby lowering costs and improving quality of life for adults with schizophrenia and major mood disorders. However, similar programs for families with impaired children are lacking. This paper reports on efforts to develop, implement, and test the efficacy of a six-session, manual-driven multi-family psy-choeducation group therapy program for families of children or adolescents with a mood disorder. In this paper we provide a clinical description of the program along with pilot data, which suggest consumer satisfaction as well as improvement in family climate following participation in this multifamily psychoeducation program.