Objective-An important question in pediatric bipolar research is whether marked nonepisodic irritability is a manifestation of bipolar disorder in youth. This study tests the hypothesis that youth with severe mood dysregulation (SMD), a category created for the purpose of studying children presenting with severe nonepisodic irritability, will be significantly less likely to develop (hypo-)manic or mixed episodes over time than will youth with bipolar disorder (BD). Method-Patients with SMD (N = 84) and narrowly defined BD (N = 93) at baseline were followed up in 6-monthly intervals using the relevant K-SADS modules to ascertain (hypo-)manic or mixed episodes.Results-Only one of 84 SMD subjects (1/84 [1.2%]; 95% confidence interval CI = 0.0003 to 0.064) experienced a (hypo-)manic or mixed episode during the study (median follow-up = 28.7 months). The frequency of such episodes was more than 50 times higher in those with narrowly defined BD (58/93 [62.4%]; 95% CI 0.52 to 0.72).Conclusions-These data suggest that, over an approximately 2-year follow-up period, youth with SMD are unlikely to develop (hypo-)manic or mixed episodes. Keywords bipolar disorder; pediatric; severe mood dysregulation; irritability; ADHD In American psychiatric clinics and inpatient settings, dramatic increases in the rates of diagnosis of pediatric bipolar disorder (BD) have been documented over the past decade, 1,2 with a concomitant increase in prescription rates for antipsychotic medication. 3 This rapid increase in the diagnosis of pediatric BD has coincided with the contention that the clinical presentation of BD differs between children and adults. 4,5 The debate regarding the pediatric presentation of BD is complex. One important aspect of it has been the suggestion that marked irritability, even when it does not constitute an episodic change from baseline, is a manifestation of BD in youth. 4,6,7 To provide a framework for research on whether irritable children without distinct manic episodes have a developmental presentation of BD, we operationalized 8 a clinical syndrome, severe mood dysregulation (SMD), designed to capture chronically irritable children whose diagnostic status is in doubt. This paper uses a longitudinal sample to investigate the extent to which subjects with SMD develop episodes of (hypo-)mania, compared to youth with narrowly defined BD.The criteria for SMD require a persistent, nonepisodic clinical presentation of negatively valenced mood with frequent and impairing anger outbursts, combined with at least three of the "B" criteria of mania (pressured speech, agitation, insomnia, and flight of ideas/racing thoughts) and one (distractibility) that is also common to ADHD. 8 A community-based follow-up study suggests that SMD is common, with a lifetime prevalence of 3.3% in youth 9 to 19 years of age. 9 Furthermore, in that sample SMD predicted depressive disorder at 7-year follow-up in youths who were 9 to 19 years old at baseline. 9 Consistent with this finding, another community-based study of nonepisod...

The ongoing release of the Human Connectome Project (HCP) data is a watershed event in clinical neuroscience. By attaining a quantum leap in spatial and temporal resolution within the framework of a twin/sibling design, this open science resource provides the basis for delineating brain-behavior relationships across the neuropsychiatric landscape. Here we focus on attention-deficit/hyperactivity disorder (ADHD), which is at least partly continuous across the population, highlighting constructs that have been proposed for ADHD and which are included in the HCP phenotypic battery. We review constructs implicated in ADHD (reward-related processing, inhibition, vigilant attention, reaction time variability, timing and emotional lability) which can be examined in the HCP data and in future “high definition” clinical datasets.

Background Distinguishing pediatric bipolar disorder (BD) from attention-deficit hyperactivity disorder (ADHD) can be challenging. Hyperactivity is a core feature of both disorders, but severely disturbed sleep and circadian dysregulation are more characteristic of BD, at least in adults. We tested the hypothesis that objective measures of activity, sleep and circadian rhythms would help differentiate pediatric subjects with BD from ADHD and typically developing controls. Methods Unmedicated youths (N=155, 97 males, age 5-18) were diagnosed using DSM-IV criteria with Kiddie-SADS PL/E. BD youths (n=48) were compared to typically developing controls (n=42) and children with ADHD (n=44) or ADHD plus comorbid depressive disorders (n=21). Three-to-five days of minute-to-minute belt-worn actigraph data (Ambulatory Monitoring Inc.), collected during the school week, were processed to yield 28 metrics per subject, and assessed for group differences with analysis of covariance. Cross-validated machine learning algorithms were used to determine the predictive accuracy of a four-parameter model, with measures reflecting sleep, hyperactivity and circadian dysregulation, plus Indic's bipolar vulnerability index (VI). Results There were prominent group differences in several activity measures, notably mean 5 lowest hours of activity, skewness of diurnal activity, relative circadian amplitude and VI. A predictive support vector machine model discriminated bipolar from non-bipolar with mean accuracy of 83.1±5.4%, ROC area of 0.781±0.071, kappa of 0.587±0.136, specificity of 91.7±5.3% and sensitivity of 64.4±13.6%. Conclusions Objective measures of sleep, circadian rhythmicity and hyperactivity were abnormal in BD. Wearable sensor technology may provide bio-behavioral markers that can help differentiate children with BD from ADHD and healthy controls.

Background An increasing number of youth are being diagnosed with, and treated for, bipolar disorder (BD). Controversy exists about whether youth with non-episodic irritability and symptoms of attention deficit hyperactivity disorder (ADHD) should be considered to have a developmental presentation of mania. Method A selective review of the literature related to this question, along with recommendations to guide clinical assessment. Results Data indicate differences between youth with episodic mania and those with non-episodic irritability in longitudinal diagnostic associations, family history, and pathophysiology. In youth with episodic mania, elation and irritability are both common during manic episodes. Conclusions In diagnosing mania in youth, clinicians should focus on the presence of episodes that consist of a distinct change in mood accompanied by concurrent changes in cognition and behavior. BD should not be diagnosed in the absence of such episodes. In youth with ADHD, symptoms such as distractibility and agitation should be counted as manic symptoms only if they are markedly increased over the youth's baseline symptoms at the same time that there is a distinct change in mood and the occurrence of other associated symptoms of mania. Although different techniques for diagnosing comorbid illnesses have not been compared systematically, it appears most rational to diagnose co-occurring illnesses such as ADHD only if the symptoms of the co-occurring illness are present when the youth is euthymic.

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Introduction: The diagnosis of bipolar disorder (BD) in youths has been controversial, especially for the subtype BD not otherwise specified (BD-NOS). In spite of growing evidence that sleep is a core feature of BD, few studies characterize and compare sleep disturbances in youth with BD type I (BD-I) and BD-NOS. Sleep disturbances are frequently reported in clinical descriptions of children and adolescents with BD, however the reporting of the frequency and characteristics of sleep symptoms in youth with BD-NOS and BD-I during episodes remain poor. This study compares symptom of sleep disturbance as occurring in manic and depressive episodes in BD-I and BD-NOS youth using Kiddie-schedule for affective disorders and schizophrenia, present and lifetime version (K-SADS-PL) interview data. The study also addresses whether symptoms of sleep disturbance vary in different age groups. Materials and Methods: The sample consisted of 70 children and adolescent outpatients at an urban specialty clinic (42M/28F, 10.8 ± 3.6 years old) including 24 BD-I and 46 BD-NOS assessed using K-SADS-PL-parent interview. Results: Sleep disturbances including insomnia and decreased need for sleep were reported by 84.3% of the sample. Enuresis was diagnosed in 27% of sample. There were no significant differences in frequency of sleep symptoms between BD-I and BD-NOS. Regardless of BD subtype, current functioning was negatively correlated with decreased need for sleep but not insomnia, and regardless of BD subtype. Conclusion: The majority of youth with BD presents with sleep symptoms during mood episodes. BD-NOS presents with the same proportion of sleep symptoms as BD-I in our sample.

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