title: Diagnostic characteristics of child bipolar I disorder: does the "Treatment of Early Age Mania (team)" sample generalize? Recognizing mania in children and adolescents-age does not matter, but decreased need for sleep does. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype.
abstract: OBJECTIVE To examine the representativeness of a r and omized controlled trial ( RCT ) sample versus one obtained by consecutive new case ascertainment , for subjects with child bipolar I disorder . METHOD Subjects ( N = 247 ) were out patients who participated in either the National Institute of Mental Health-funded Phenomenology and Course of Pediatric Bipolar Disorders study or the Treatment of Early Age Mania ( TEAM ) study . Both studies required that subjects have current DSM-IV bipolar I disorder ( manic or mixed phase ) and a Children 's Global Assessment Scale ( CGAS ) score < or=60 . All subjects had elation and /or gr and iosity . Subjects in the Phenomenology study were obtained from 1995 to 1998 by consecutive new case ascertainment from design ated pediatric and psychiatric facilities . Subjects in the  TEAM RCT were recruited from media and community sources between March 2003 and March 2005 . Assessment instruments included the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia , given separately to parents about their children and to children about themselves , and the CGAS . Logistic regression was used for comparisons . RESULTS The TEAM and Phenomenology groups were similar in age ( 10.4 [ SD = 2.3 ] , 10.9 [ SD = 2.3 ] years , respectively ) and other demography . Both had long current episode duration ( 4.8 [ SD = 2.4 ] , 3.2 [ SD = 2.3 ] years ) and low lifetime use of any mood stabilizer ( 23.6 % , 35.0 % ) . Many mania symptoms and ultradian rapid cycling , psychosis , and suicidality were significantly more prevalent in the RCT sample . CONCLUSIONS Generalization of the RCT sample was supported , because only 7.8 % of Phenomenology subjects did not fit the RCT criteria . Nevertheless , because the RCT subjects were more severely ill , it is unclear if treatment findings from the RCT will be applicable to children with less severe mania . CLINICAL TRIALS REGISTRATION Clinical Trials.gov identifier NCT00057681 ( TEAM study ) BACKGROUND The diagnosis of pediatric bipolar disorders is a controversial topic . If this is mainly due to a bias against a diagnosis in younger children , then just changing the information about the age of a patient should influence the likelihood of a diagnosis despite otherwise identical symptoms . Therefore , we design ed a study to test if the age of a patient will influence diagnostic decisions . We further attempted to replicate an earlier result with regard to " decreased need for sleep " as a salient symptom for mania . METHODS We r and omly sent 1 of 4 case vignettes describing a person with current mania to child/adolescents psychiatrists in Germany . This vignette was systematic ally varied with respect to age of the patient ( 6 vs 16 years ) and the presence/absence of decreased need for sleep but always included sufficient criteria to diagnose a mania . RESULTS One hundred sixteen responded and , overall , 63.8 % of the respondents diagnosed a bipolar disorder in the person described in the vignette . Although age did not affect the likelihood of a bipolar diagnosis , the presence of decreased need for sleep did increase its likelihood . Furthermore , the number of core symptoms identified by the clinicians was closely linked to the likelihood of assigning a bipolar diagnosis . CONCLUSION Certain symptoms such as the decreased need for sleep , and also elated mood and gr and iosity , seem to be salient for some clinicians and influence their diagnoses . Biological age of the patient , however , does not seem to cause a systematic bias against a diagnosis of bipolar disorder in children BACKGROUND Diagnosis of child mania has been contentious . OBJECTIVE To investigate natural history and prospect i ve validation of the existence and long-episode duration of mania in children . DESIGN Four-year prospect i ve longitudinal study of 86 subjects with intake episode mania who were all assessed at 6 , 12 , 18 , 24 , 36 , and 48 months . The phenotype was defined as DSM-IV bipolar I disorder ( manic or mixed ) with at least 1 cardinal symptom ( elation and /or gr and iosity ) to ensure differentiation from attention-deficit/hyperactivity disorder . Parent and child informants were separately interviewed , by highly experienced research nurses , using the Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia ( WASH-U-KSADS ) . A Children 's Global Assessment Scale score of 60 or less was needed to establish definite impairment . Treatment was by subjects ' community practitioners . SETTING Research unit in a university medical school . PARTICIPANTS Subjects were obtained from psychiatric and pediatric sites by consecutive new case ascertainment , and their baseline age was 10.8 + /- 2.7 years . Onset of the baseline episode  was 7.4 + /- 3.5 years . ( Data are given as mean + /- SD . ) MAIN OUTCOME MEASURES Episode duration , weeks ill , recovery/relapse rates , and outcome predictors . RESULTS Prospect i ve episode duration of manic diagnoses , using onset of mania as baseline date , was 79.2 + /- 66.7 consecutive weeks . Any bipolar disorder diagnosis occurred during 67.1 % + /- 28.5 % of total weeks , during the 209.4 + /- 3.3 weeks of follow-up . Subjects spent 56.9 % + /- 28.8 % of total weeks with mania or hypomania ( unipolar or mixed ) , and 38.7 % + /- 28.8 % of these were with mania . Major or minor depression and dysthymia ( unipolar or mixed ) occurred during 47.1 % + /- 30.4 % of total weeks . Polarity switches occurred 1.1 + /- 0.7 times per year . Low maternal warmth predicted faster relapse after recovery from mania ( chi(2 ) = 13.6 , P = .0002 ) , and psychosis predicted more weeks ill with mania or hypomania ( F(1,80 ) = 12.2 , P = .0008 ) . Pubertal status and sex were not predictive . ( Data are given as mean + /- SD . ) CONCLUSIONS These findings vali date the existence , long-episode duration , and chronicity of child mania . Differences from the natural history of adult bipolar disorder are discussed
target: Comparison of manic symptoms across age groups suggested that irritability is a key feature of BD with an onset in childhood , activity is the most prominent in adolescent-onset BD and pressure of speech is more characteristic of adult-onset BD .
  Conclusions Despite frequent discussion of similarities and differences in phenomenology of mania presenting in different age groups , systematic research is lacking and studies are still required to reliably establish whether the frequency and severity of manic symptoms varies .
background: Background In the last two decades , there has been a significant increase in the diagnosis of Bipolar Disorder ( BD ) in children .
  The notion of prepubertal onsets of BD is not without controversy , with research ers debating whether paediatric cases have a distinct symptom profile or follow a different illness trajectory from other forms of BD .
  The latter issue is difficult to address without long-term prospect i ve follow-up studies .
  However , in the interim , it is useful to consider the phenomenology observed in groups of cases with different ages of onset and particularly to compare manic symptoms in children diagnosed with BD compared to cases presenting with BD in adolescence and adulthood .
  This review systematic ally explores the phenomenology of manic or hypomanic episodes in groups defined by age at onset of BD ( children , adolescents and adults ; or combined age groups e.g. children and adolescents versus adults ) .