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One approach suggested for building a communication platform was to operationalize in a more refined way dimensions of the various behavior problems seen in these children that may or may not meet specific criteria for disorders. This could be accomplished by collecting instruments for each dimension, preparatory to obtaining general agreement on the assessment of the various dimensions and developing a common battery for multi-informant assessments. Alternatively, it was suggested that these dimensions could be assessed with measures of individual choice and that the Child Behavior Checklist (CBCL), less likely to be affected by measurement and diagnostic differences, could then be used for calibration across sites.
With regard to comorbidity, it was recommended that assessment not rely strictly on DSM criteria to determine absence or presence of co-occurring disorders, as subthreshold clinical conditions may be important as well.
Once there is agreement on exclusion criteria (i.e., certain comorbidities [e.g., Pervasive Developmental Disorder] and/or physical disease) as well as inclusion criteria for the broader phenotype, it should be possible to address questions about etiological relationships among the disorders; e.g., whether Bipolar-NOS or subtypes of Bipolar-NOS are precursors of Bipolar-I and/or Bipolar II or have a different course. It was noted, for instance, that whereas classic manic-depressive course includes well periods, these children tend to have none. Moreover, it should be possible to identify and fully characterize children who have bipolar symptoms and are severely impaired and to follow them prospectively, with attention to developmental stages and transitions, in order to resolve whether they have a childhood-onset variant of bipolar disorder.
Validation studies also should take developmental manifestations into consideration. It was suggested that studies could go down in age range as far as four years of age. Reconstruction of the history of adults with early-onset bipolar illness may be useful as well. For example, in studies of offspring of bipolar parents, in which all of their children should be included, parents should be asked also about their own age at onset. In studies of both children who appear to have bipolar illness and children who may have bipolar illness, it was considered important that the children as well as their parents be interviewed with developmentally appropriate measures.
Diagnostic Instruments Currently Used in Studies of Bipolar Disorder in Children
Following the meeting, Dr. Geller, with assistance from Dr. Birmaher, assembled information about instruments currently in use in NIMH-funded studies of childhood-onset bipolar disorder. Their report can be found at http://www.nimh.nih.gov/index.shtml The most commonly used diagnostic instrument is the KSADS; in most cases the WASH-U-KSADS or with the addition of the WASH-U-KSADS mood disorders and rapid cycling sections. Ancillary instruments that are being used include the CBCL, Mania Rating Scale, KSADS mania rating scale, and CGAS. It appears that assessment of mood lability is a challenge at all age levels.
Questions to be Addressed (via e-mail, conference calls, further meetings)
Outstanding issues include the following:
- Describing the course of Bipolar-I, Bipolar-II, cyclothymia, and Bipolar-NOS, with attention to possible developmental changes in symptom expression, with the goal of establishing the predictive validity of bipolar disorder in prepubertal children
- Defining thresholds for and boundaries between Bipolar-I, Bipolar-II, and cyclothymia in prepubertal children
- Defining occasions for combining versus separating Bipolar-I and Bipolar-II (For instance, in treatment studies of mania, where severity is an issue, combining manic with hypomanic patients may not be appropriate. However, combining should be appropriate when the focus of treatment is on decreasing number of cycles. Data from genetic studies suggest similarities as well as differences between Bipolar-I and Bipolar-II.)
- Establishing inclusion and exclusion criteria for Bipolar-NOS (and identifying subtypes?)
- Developing a common battery for the assessment of impairing behaviors in children who have and who may have bipolar disorder
According to the Robins and Guze model as expanded by Cantwell (1996), the stages for establishing the validity of disorders includes studies of:
- Clinical phenomenology of the disorder: the core clinical picture and it common associated features, subtypes, and comorbidities;
- Demographic factors (incidence, prevalence, morbidity risk, and life time expectancy) and documentation of age, gender, social class, ethnicity, and culture;
- Biological factors correlated with a particular clinical picture (presence of damage and/or brain dysfunction, physical handicaps and disorders, neurological disorders) and laboratory studies in the areas of neurophysiology, neuroendocrinology, biochemistry, neuropharmacology, brain imaging, and neuropsychology;
- Family environmental factors (e.g., discipline styles and other aspects of parent-child interaction);
- Family genetics, including family aggregation, adoption, twin, linkage, segregation, gene mapping, etc.
- Natural history of the disorder, including true prospective, true retrospective, catch up prospective and anterospective studies to explore continuities and discontinuities between childhood, adolescent, and adult disorders and the mechanism for these continuities and discontinuities;
- Response to intervention.
Some of the work is ongoing. This model nevertheless can serve as a touchstone to set goals and mark progress.
next: Early Recognition and Treatment Bipolar Disorder In Children and Adolescents and Schizophrenia
Reference:
Cantwell, D.P. (1996) Classification of child and adolescent psychopathology. Journal of Child Psychology and Psychiatry, 37, 3-12.
Contact:
Editha D. Nottelmann, Ph.D.
Chief, Mood, Anxiety, and Regulatory Disorders Program
Developmental Psychopathology and Prevention Research Branch
National Institute of Mental Health
6001 Executive Boulevard, Rm. 6200 MSC9617
Bethesda, MD 20892-9617
Tel. 301-443-5944
FAX 301-480-4415
e-mail:
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next: Early Recognition and Treatment Bipolar Disorder In Children and Adolescents and Schizophrenia
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