Editorial

Changing Perspectives on Mood Disorders

in Children

I nterest in childhood mood disorders has increased substantially in recent years. This
has served as an important antidote to earlier views that assumed, largely on a theoret-
ical basis, that mood disorders were uncommon in children (1). However, the realiza-
tion that these conditions could be observed in childhood and that they shared impor-
tant core features with mood disorders in adolescents and adults also came with an
awareness of the important effects of development and developmental level on the ex-
pression of these conditions. Research and clinical work in childhood mood disorders
has been complicated by factors such as the difficulties around differential diagnosis,
since the initial presentation may be misleading and diagnostic certainty may be
achieved only over time and with the wisdom of hindsight. For example, a child with bi-
polar disorder can initially exhibit symptoms of
overactivity and inattention, and a child with
major depression may display irritable mood “The lack of treatment
and anxiety rather than overt depression as the efficacy data on these
prominent feature. Further problems are posed
by the potential for serious mood disorders to
conditions is most
impact negatively on the child’s development unfortunate.”
and, in turn, for the child’s developmental level
to modify the presentation of the disorder (1).
Three articles in this issue are concerned with mood disorders in children.
Miller and colleagues evaluated the influence of clinical variability and sex differ-
ences on regional measures of EEG asymmetry in adults with histories of childhood-on-
set depression. As they note in their article, this work is based on the findings that asym-
metry in frontal brain activity may be a marker for vulnerability to depression and a
more general pattern of differences in right and left cortical modulation of emotional
expression. In their study, Miller et al. evaluated 55 young adults with histories of well-
documented childhood-onset depression and 55 adults with no psychiatric history.
EEG patterns were then related to childhood and adult diagnoses; EEG asymmetry dif-
ferences varied with gender and current symptoms as well as with diagnostic history
(e.g, for those individuals with childhood-onset depression who eventually exhibited
bipolar disorder). As Miller and her colleagues note, the observed sex differences in EEG
asymmetry are particularly important and emphasize the need for future work; such
differences are also of interest in light of reported differences in drug responsiveness
and the potential for providing more robust biological markers (2).
Geller and co-workers report the results of a 2-year prospective follow-up of children
with prepubertal and early adolescent bipolar disorder. As they note, there has been a
relative dearth of research on the course of early-onset bipolar disorder. They studied a
large group of patients over a 2-year period and, it is important to note, required the
presence of mania with elation or grandiosity for study inclusion, thus avoiding the po-
tential for diagnosis to be based only on the criterion for mania (which overlaps with at-
tention deficit hyperactivity disorder [ADHD]). In effect, their use of this criterion
means that they selected a group of subjects for whom there would be the most agree-
ment that they did indeed exhibit stringently defined bipolar disorder. As Geller and
colleagues note, rates of relapse were quite high. Living in an intact biological family
was a predictor of positive outcome, whereas low maternal warmth was a significant
predictor of rate of relapse. While various explanations for the relatively poor outcome
must be considered, the important possibility that children are less responsive to mood

Am J Psychiatry 159:6, June 2002 893

EDITORIAL

stabilizers cannot be ruled out. The Geller et al. data add significantly to the small but
growing body of work on prepubertal-onset bipolar disorder (3).
In their clinical case conference, State and colleagues address the problem of mania
and ADHD in a prepubertal child. The boundary between these two conditions has
proven a rather difficult one to demarcate (in contrast to adolescence, in which the ma-
jor differential diagnosis is with schizophrenia [4]). As State et al. note, the nature of the
association between ADHD and bipolar disorder remains controversial, with some argu-
ing that the association is a “true” one (5) and others arguing equally as strong that is it
artifactual (6). This debate is an important one, since the tendency to see multiple true
disorders would logically lead to polypharmacy, which may or may not be justified. This
clinical case conference captures many aspects of this current debate: the child had a
history of attentional difficulties and impulsivity and a family history of mood disorder
and was first hospitalized for threatening suicide. Although his depressed mood im-
proved following hospitalization, his attentional problems continued. After the intro-
duction of methylphenidate to treat the latter difficulties, he developed more overtly
manic symptoms, including pressured speech, diminished sleep, aggression, agitation,
and possible grandiosity. The introduction of lithium and haloperidol was associated
with some improvement, but eventually the patient was hospitalized on a third occasion
following escalating behavioral difficulties. State and colleagues rightly emphasize the
adverse impact of the child’s psychiatric problems on his educational achievement and
the difficulties of differential diagnosis in a child whose disorder is evolving over time.
Their report also underscores the need for additional data to address the problems of co-
morbidity with ADHD. This problem is particularly important, since children often do
not exhibit the more typical euphoria and grandiosity of adults. The problem of comor-
bidity here is a significant one in that treatment with stimulants or antidepressants may
precipitate mood episode switches, although this issue remains controversial.
These three studies underscore the importance of research on childhood mood disor-
ders. The lack of treatment efficacy data on these conditions is most unfortunate. As
State and colleagues indicate, there are currently no placebo-controlled trials of mood-
stabilizing agents in children with bipolar disorder. Various issues remain to be resolved
by future research. These include the problem of comorbidty and the issue of whether
more sophisticated diagnostic schemes are needed for this population. The important
issue of the treatment of attentional symptoms in children with family histories of
mood disorder or features suggestive of mood disorder also remains a major priority.

References

1. Volkmar FR: Childhood and adolescent psychosis: a review of the past 10 years. J Am Acad Child Adolesc Psy-
chiatry 1996; 35:843–851
2. Bruder GE, Stewart JW, Tenke CE, McGrath PJ, Leite P, Bhattacharya N, Quitkin FM: Electroencephalographic
and perceptual asymmetry differences between responders and nonresponders to an SSRI antidepressant.
Biol Psychiatry 2002; 49:416–425
3. Carlson GA, Bromet EJ, Sievers S: Phenomenology and outcome of subjects with early- and adult-onset psy-
chotic mania. Am J Psychiatry 2000; 157:213–219
4. McGlashan TH: Adolescent versus adult-onset mania. Am J Psychiatry 1988; 145:221–223
5. Biederman J: Resolved: mania is mistaken for ADHD in prepubertal children (affirmative). J Am Acad Child
Adolesc Psychiatry 1998: 37:1091–1093
6. Klein RG, Pine DS, Klein DF: Resolved: mania is mistaken for ADHD in prepubertal children (negative). J Am
Acad Child Adolesc Psychiatry 1998; 37:1093–1096

FRED R. VOLKMAR, M.D.

Address reprint requests to Dr. Volkmar, Yale University Child Study Center, 230 South Frontage Rd., P.O. Box
207900, New Haven, CT 06520-7900; fred.volkmar@yale.edu (e-mail).

894 Am J Psychiatry 159:6, June 2002