Factors associated with mental health service utilization among bipolar youth.

OBJECTIVES: This study aims to characterize patterns of mental health service utilization within a sample of bipolar youth. Demographic variables, youth bipolar characteristics, youth comorbid conditions, and parental psychopathology were examined as predictors of treatment utilization across different levels of care. METHODS: A total of 293 bipolar youth (aged 7-17 years) and their parents completed a diagnostic interview, family psychiatric history measures, and an assessment of mental health service utilization. Demographic and clinical variables were measured at baseline and mental health service use was measured at the six-month follow-up. RESULTS: Approximately 80% of bipolar youth attended psychosocial treatment services over the span of 6 months. Of those who attended treatment, 67% attended only outpatient services, 22% received inpatient/partial hospitalization, and 12% received residential/therapeutic school-based services. Using multinomial logistic regression, older age, female gender, and bipolar characteristics, including greater symptom severity and rapid cycling, were found to predict higher levels of care. Youth suicidal and non-suicidal self-injurious behavior, comorbid conduct disorder, and parental substance use disorders also predicted use of more restrictive treatment settings. CONCLUSIONS: Results underscore the importance of assessing for and addressing suicidality, comorbid conduct disorder, and parental substance use disorders early in the treatment of bipolar youth to potentially reduce the need for more restrictive levels of care.

Childhood-onset bipolar disorder: Evidence for increased familial loading of psychiatric illness.

OBJECTIVE: To determine whether childhood-onset bipolar disorder (BP) is associated with an increased psychiatric family history compared with adolescent-onset BP. METHOD: Semistructured psychiatric interviews were conducted for 438 youth with BP spectrum disorders. To evaluate the effects of age at onset and psychiatric family history, the sample was divided into childhood-onset BP (age and BP onset <12 years; n = 192), adolescents with early-onset BP (age > or =12 years and BP onset <12 years; n = 136), and adolescents with late-onset BP (age and BP onset > or =12 years; n = 110). Lifetime family history of psychiatric illness was ascertained for first- and second-degree relatives through both direct interview of caretakers and the Family History Screen. RESULTS: After significant demographic and clinical factors were controlled for, children and adolescents with childhood-onset BP showed higher percentages of positive first-degree family history for depression, anxiety, attention-deficit/hyperactivity, conduct, and substance dependence disorders and suicidal behaviors compared with adolescents with late onset. Subjects with childhood-onset BP also showed elevated familial loading for depression and attention-deficit/hyperactive disorder in second-degree relatives. CONCLUSIONS: These data support a model that postulates a higher density of familial risk for a broad range of psychopathology in childhood-onset BP.

Phenomenology of children and adolescents with bipolar spectrum disorders.

CONTEXT: Children and adolescents who present with manic symptoms frequently do not meet the full DSM-IV criteria for bipolar I disorder (BP-I). OBJECTIVE: To assess the clinical presentation and family history of children and adolescents with BP-I, bipolar II disorder (BP-II), and bipolar disorder not otherwise specified (BP-NOS). DESIGN: Subjects and their primary caretaker were assessed by semistructured interview, and family psychiatric history was obtained from interview of the primary caretaker. SETTING: Outpatient and inpatient units at 3 university centers. PARTICIPANTS: A total of 438 children and adolescents (mean +/- SD age, 12.7 +/- 3.2 years) with BP-I (n = 255), BP-II (n = 30), or BP-NOS (n = 153). MAIN OUTCOME MEASURES: Lifetime psychiatric history and family history of psychiatric disorders. RESULTS: Youth with BP-NOS were not diagnosed as having BP-I primarily because they did not meet the DSM-IV duration criteria for a manic or mixed episode. There were no significant differences among the BP-I and BP-NOS groups in age of onset, duration of illness, lifetime rates of comorbid diagnoses, suicidal ideation and major depression, family history, and the types of manic symptoms that were present during the most serious lifetime episode. Compared with youth with BP-NOS, subjects with BP-I had more severe manic symptoms, greater overall functional impairment, and higher rates of hospitalization, psychosis, and suicide attempts. Elevated mood was present in 81.9% of subjects with BP-NOS and 91.8% of subjects with BP-I. Subjects with BP-II had higher rates of comorbid anxiety disorders compared with the other 2 groups and had less functional impairment and lower rates of psychiatric hospitalization than the subjects with BP-I. CONCLUSIONS: Children and adolescents with BP-II and BP-NOS have a phenotype that is on a continuum with that of youth with BP-I. Elevated mood is a common feature of youth with BP-spectrum illness.

Pediatric bipolar disease: current and future perspectives for study of its long-term course and treatment.

AIM AND METHODS: Findings from recent long-term, prospective longitudinal studies of the course, outcome and naturalistic treatment of adults with bipolar illness are highlighted as background for long-term developmental study of pediatric bipolar illness. RESULTS: Accumulating knowledge of bipolar illness in adults underscores a high risk for multiple recurrences through the lifespan, significant medical morbidity, high rates of self-harm, economic and social burden and frequent treatment resistance with residual symptoms between major episodes. At present, there is no empirical foundation to support any assumption about the long-term course or outcome of bipolar illness when it arises in childhood or adolescence, or the effects of conventional pharmacotherapies in altering its course and limiting potentially adverse outcomes. The proposed research articulates specific descriptive aims that draw on adult findings and outlines core methodological requirements for such an endeavor. CONCLUSIONS: Innovations in the description and quantitative analysis of prospective longitudinal clinical data must now be extended to large, systematically ascertained pediatric cohorts recruited through multicenter studies if there is to be a meaningful scientific advance in our knowledge of the enduring effects of bipolar illness and the potential value of contemporary approaches to its management.

Child comorbidity, maternal mood disorder, and perceptions of family functioning among bipolar youth.

OBJECTIVE: To examine the association between youth comorbid psychiatric disorders, maternal mood disorder, and perceptions of family cohesion and conflict among youth diagnosed with pediatric bipolar disorder (PBD). METHOD: Three hundred eighty-nine bipolar youths and their parents completed a diagnostic interview and instruments assessing family psychiatric history and functioning. Family functioning was assessed with the Family Adaptability and Cohesion Scales-II and the Conflict Behavior Questionnaire. RESULTS: The presence of a maternal mood disorder was associated with lower family cohesion. The presence of a youth externalizing disorder with or without a co-occurring anxiety disorder was also associated with lower family cohesion as well as higher family conflict. Furthermore, the negative relationship between maternal mood disorder and family functioning was stronger in the presence of a youth externalizing disorder. CONCLUSIONS: Youth comorbidity and maternal mood disorders appear to be associated with worse family functioning among bipolar youths. Family-based treatments with bipolar youths may need to integrate treatment of youth comorbidity and address maternal mood disorder for optimal results.

Psychotic symptoms in pediatric bipolar disorder and family history of psychiatric illness.

BACKGROUND: Few studies have examined the specificity and non-specificity in patterns of familial loading for presentation of psychotic symptoms in pediatric bipolar disorder (BP). METHODS: Diagnostic assessment of 263 pediatric BP probands included lifetime history of psychotic symptoms as well as longitudinal follow-up; family history of psychiatric illness was determined for 1st degree relatives. RESULTS: Pediatric BP probands with lifetime history of psychosis had a higher percentage of positive family history of anxiety disorders and suicide attempts as compared to probands with no history of psychosis. DISCUSSION: Familial loading for a spectrum of internalizing disorders is associated with presentation of psychotic symptoms in pediatric BP.

Abusive parents' reports of child behavior problems: relationship to observed parent-child interactions.

PURPOSE: We evaluated the hypothesis that abusive parents' reports may exaggerate rates of child behavior problems in a clinical sample. METHOD: The association between parental ratings of behavior problems and independent observations of child behaviors was examined in a sample of 205 clinic-referred families, 58 of which had a reported history of physical abuse. RESULTS: Relative to the comparison group, parents in the abuse group reported more externalizing problems in their children after controlling for parental psychopathology, and displayed more emotionally controlling and less supportive behavior during parent-child interactions. However, there was no association between abuse history and observed child behaviors during the interaction tasks. Abuse status significantly moderated the association between parent-reported externalizing behaviors and observed demanding behavior by the child; the association was significant among comparison families, but not in the abuse group families. CONCLUSIONS: Results indicate that abusive parents may over-report externalizing behavior problems in their children.

Clinical course of children and adolescents with bipolar spectrum disorders.

CONTEXT: Despite the high morbidity associated with bipolar disorder (BP), few studies have prospectively studied the course of this illness in youth. OBJECTIVE: To assess the longitudinal course of BP spectrum disorders (BP-I, BP-II, and not otherwise specified [BP-NOS]) in children and adolescents. DESIGN: Subjects were interviewed, on average, every 9 months for an average of 2 years using the Longitudinal Interval Follow-up Evaluation. SETTING: Outpatient and inpatient units at 3 university centers. PARTICIPANTS: Two hundred sixty-three children and adolescents (mean age, 13 years) with BP-I (n = 152), BP-II (n = 19), and BP-NOS (n = 92). MAIN OUTCOME MEASURES: Rates of recovery and recurrence, weeks with syndromal or subsyndromal mood symptoms, changes in symptoms and polarity, and predictors of outcome. RESULTS: Approximately 70% of subjects with BP recovered from their index episode, and 50% had at least 1 syndromal recurrence, particularly depressive episodes. Analyses of weekly mood symptoms showed that 60% of the follow-up time, subjects had syndromal or subsyndromal symptoms with numerous changes in symptoms and shifts of polarity, and 3% of the time, psychosis. Twenty percent of BP-II subjects converted to BP-I, and 25% of BP-NOS subjects converted to BP-I or BP-II. Early-onset BP, BP-NOS, long duration of mood symptoms, low socioeconomic status, and psychosis were associated with poorer outcomes and rapid mood changes. Secondary analyses comparing BP-I youths with BP-I adults showed that youths significantly more time symptomatic and had more mixed/cycling episodes, mood symptom changes, and polarity switches. CONCLUSIONS: Youths with BP spectrum disorders showed a continuum of BP symptom severity from subsyndromal to full syndromal with frequent mood fluctuations. Results of this study provide preliminary validation for BP-NOS.

Effects of psychotherapy for depression in children and adolescents: a meta-analysis.

Serious sequelae of youth depression, plus recent concerns over medication safety, prompt growing interest in the effects of youth psychotherapy. In previous meta-analyses, effect sizes (ESs) have averaged .99, well above conventional standards for a large effect and well above mean ES for other conditions. The authors applied rigorous analytic methods to the largest study sample to date and found a mean ES of .34, not superior but significantly inferior to mean ES for other conditions. Cognitive treatments (e.g., cognitive-behavioral therapy) fared no better than noncognitive approaches. Effects showed both generality (anxiety was reduced) and specificity (externalizing problems were not), plus short- but not long-term holding power. Youth depression treatments appear to produce effects that are significant but modest in their strength, breadth, and durability.

History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk.

BACKGROUND: Despite evidence indicating high morbidity associated with pediatric bipolar disorder (BP), little is known about the prevalence and clinical correlates of suicidal behavior among this population. OBJECTIVE: To investigate the prevalence of suicidal behavior among children and adolescents with BP, and to compare subjects with a history of suicide attempt to those without on demographic, clinical, and familial risk factors. METHODS: Subjects were 405 children and adolescents aged 7-17 years, who fulfilled DSM-IV criteria for BPI (n = 236) or BPII (n = 29), or operationalized criteria for BP not otherwise specified (BP NOS; n = 140) via the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. As part of a multi-site longitudinal study of pediatric BP (Course and Outcome of Bipolar Youth), demographic, clinical, and family history variables were measured at intake via clinical interview with the subject and a parent/guardian. RESULTS: Nearly one-third of BP patients had a lifetime history of suicide attempt. Attempters, compared with non-attempters, were older, and more likely to have a lifetime history of mixed episodes, psychotic features, and BPI. Attempters were more likely to have a lifetime history of comorbid substance use disorder, panic disorder, non-suicidal self-injurious behavior, family history of suicide attempt, history of hospitalization, and history of physical and/or sexual abuse. Multivariate analysis found that the following were the most robust set of predictors for suicide attempt: mixed episodes, psychosis, hospitalization, self-injurious behavior, panic disorder, and substance use disorder. CONCLUSIONS: These findings indicate that children and adolescents with BP exhibit high rates of suicidal behavior, with more severe features of BP illness and comorbidity increasing the risk for suicide attempt. Multiple clinical factors emerged distinguishing suicide attempters from non-attempters. These clinical factors should be considered in both assessment and treatment of pediatric BP.

Parent-child interactions in relation to critical and emotionally overinvolved expressed emotion (EE): is EE a proxy for behavior?

Expressed emotion measures, encompassing dimensions of criticism (CRIT), and emotional overinvolvement (EOI) are increasingly being used to assess the parent-child relationship in child clinical populations, despite the lack of studies assessing their validity. We examined the correspondence between CRIT, EOI, and parent-child interactions as observed by neutral coders in a sample of 252 clinic-referred children and adolescents, ages 7-17 years. We found support for the validity of the CRIT code, with high critical parents showing more antagonism, negativity, disgust, harshness, and less responsiveness, compared to parents who scored in the low or borderline ranges. In contrast, none of the observed behaviors were found to correspond with parental EOI, suggesting either that this construct lacks validity with juvenile samples or that behaviors that correspond to EOI are difficult to observe. We conclude that high parental CRIT can be used as an index of problematic parent-child interactions.

Predictors of continued suicidal behavior in adolescents following a suicide attempt.

Describes adolescents who attempt suicide and their risk for ongoing suicidal behavior. Fifty-eight adolescents (53 female) who attempted suicide received a baseline evaluation that was analyzed to identify factors that were associated with continued suicidal ideation and reattempt. At a 3-month follow-up assessment, 45% reported continued suicidal ideation and 12% reported a repeat attempt. Baseline measures of family functioning, feelings of hopelessness, and abilities to regulate affect were associated with suicidal ideation at follow-up but not as strongly as depressed mood. After controlling for depressive symptoms, the association between family functioning and continued suicidal behavior was no longer significant. Depressed mood at baseline was most strongly associated with both continued suicidal ideation and reattempt.