The 24-month course of manic symptoms in children.

Youth receiving mental health services often experience numerous mania-like symptoms (1, 2). Furthermore, although symptoms of mania are, by definition, present in youth suffering from bipolar disorder, prior data have noted that many youth who experience manic symptomatology do not suffer from bipolar disorder (3-7). Whether or not a youth has suffered from a bipolar disorder, it has been noted that elevated symptoms of mania (ESM) are associated with substantial psychosocial impairments and notable degrees of psychopathology (7-9). Despite these initial investigations of children who experience ESM, very little is known about the phenomenology or symptomatic course of ESM in youth. Data from a pilot study suggested that the presence of ESM in children with attention-deficit hyperactivity disorder (ADHD) may be associated with a poorer outcome (9, 10). The National Institute of Mental Health (NIMH)-supported Longitudinal Assessment of Manic Symptoms (LAMS) study was designed to better understand the phenomenology and determinants of outcome (e.g., psychosocial functioning, diagnoses, medications, and service utilization) in children with ESM. LAMS used an epidemiological approach to assemble a cohort of 6–12-year-old children at their first outpatient mental health visit at university-affiliated clinics (11). The LAMS design used a low, sensitive threshold on a screening instrument for manic symptoms, both to capture a large portion of those already showing symptoms of bipolarity, but also to include a substantial number of cases without bipolarity who were also experiencing similar emotional and behavioral dysregulation. Initial results have confirmed the finding that ESM in clinical mental health settings for youth are, in fact, common and that the majority of children with ESM indeed do not meet DSM-IV criteria for a bipolar spectrum disorder at baseline (5). The most common diagnoses are ADHD, oppositional defiant disorder, conduct disorder, and depression, often in various combinations (3, 5, 12). A specific goal of the LAMS study was to examine the course of children’s manic symptoms over time. To this end, we evaluated whether or not children who participated demonstrated different trajectories of parent-reported manic and biphasic symptoms over the first 24 months of follow-up. Based on prior longitudinal investigations of diagnostic status, combined with the choice of a low threshold of ESM to capture a heterogeneous group of youths in terms of clinical issues, we anticipated that there would be several distinct symptom trajectories, including at least one group that showed persistent symptoms of mania and at least one group that remitted. We also anticipated that a third group might show intermediate levels of mood symptoms, but whether this would be a stable pattern, or whether manic symptoms would fluctuate, was an empirical question. We next investigated what baseline determinants differentiated these distinct trajectories. Finally, we investigated what factors occur over the span of an initial 24-month observation period that could lead to categorization into these distinct classes.