Vele mensen zullen het gevoel wel kennen, ze zitten aan de antibiotica, maar hebben dan een feestje amoxicilline kopen zonder recept Antibiotica zijn medicijnen die alleen op recept te krijgen zijn.
Running head: pediatric bipolar disorder
The Enigma of Bipolar Disorder in Children and Adolescents
In the past decade, there has been a proliferation in the number of children and
adolescents diagnosed with bipolar disorder. Except in rare cases, the young people
who receive this diagnosis do not meet the strict diagnostic criteria for bipolar disorder I
or II in the DSM-IV-TR. Many pediatric psychiatrists insist there are important
development differences in the manifestation of bipolar disorder in childhood and
adolescence. In place of clear-cut episodes of mania/hypomania and depression, they
argue that younger people with the disorder experience chronic irritability, aggressive
behavior, impulsivity, extremely rapid mood swings, hyperactivity, and severe temper
tantrums. Given that many of the young people pose special challenges to the school
system, the purpose of this article is to update school counselors on this controversial
expansion of the diagnosis and treatment of bipolar disorder among children and
The Enigma of Bipolar Disorder in Children and Adolescents
Among a multitude of other responsibilities, school counselors have an important
role to play in the school system in identifying and serving students who may be
experiencing severe mental health problems (Ritchie & Partin, 1994). Yet, discharging
this responsibility can be difficult because school counselors typically receive very little,
if any, training in the use of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR; American Psychiatric Association, 2000). Though access to a DSM-IV-TR
manual may provide school counselors with some diagnostic possibilities, the
differential diagnostic process subsumed under the DSM-IV-TR is very complex and
requires years of training and supervised experience to master. Furthermore, the
diagnostic principle of clinical judgment allows mental health professionals a great deal
of latitude in assigning diagnoses to clients who do not neatly fit the diagnostic criteria
for specific disorders. Because of this principle, school counselors may find themselves
working with students who do not meet the diagnostic criteria for the diagnoses included
in their medical records or individualized educational plans. Nowhere is this problem
more apparent than the emerging phenomenon of pediatric bipolar disorder.
In an article describing the most common mental disorders encountered by
school counselors, Geroski, Rodgers, and Breen (1997) did not provide any details
about bipolar disorder because of their assertion that this disorder was relatively rare in
school settings. Unfortunately, this statement no longer applies (e.g., Bardick & Bernes,
2005). School counselors have found themselves working with an increasing number of
students who have been diagnosed with bipolar disorder. This pattern is disconcerting
not only because of the seemingly high prevalence rates, but also because most of the
young people who receive this diagnosis do not meet the official criteria for Bipolar I or II
in the DSM-IV-TR. (American Psychiatric Association, 2000; Wozniak et al., 1995).
Unbeknown to many counselors, the conceptualization of bipolar disorder in the
psychiatric literature has been expanded to include a range of emotional dysregulation
problems not specifically included in the DSM-IV-TR, such as pediatric bipolar disorder
(e.g., Carlson, 1998). Children and adolescents are now being diagnosed with bipolar
disorder for exhibiting severe emotional and behavioral instability in the absence of any
discrete episodes of mania, hypomania, or depression as required by the DSM-IV-TR
(e.g., Weckerly, 2002). Consequently, the purpose of this article is to update school
counselors on the controversial diagnosis and treatment of bipolar disorder in school-
aged children. This information will help school counselors both better understand the
manifestation of bipolar disorder in school-aged children and improve referral decisions
by presenting treatment strategies that are likely to be effective for this population.
Bipolar disorder was once considered to be extremely rare before early
adulthood (Kosten & Kosten, 2004; Weckerly, 2002; Youngstrom, Meyers, Youngstrom,
Calabrese, & Findling, 2006). For many years, children and adolescents who exhibited
severe mood swings and highly erratic behavior were likely to be diagnosed with a
psychotic disorder, such as schizophrenia (Carlson, 1990). Yet, in recent years,
systematic research studies have uncovered a dramatic increase in the number of
children and adolescents being diagnosed with bipolar disorder. In one of these studies,
Blader and Carlson (2007) examined the records of children and adolescents involved
in the National Hospital Discharge Survey that covered the years from 1996 to 2004. In
1996, only 10% of young people were discharged from hospitals with a diagnosis of
bipolar disorder, a figure that rose to 34% just 10 years later. In another recent study,
Moreno et al. (2007) compared the number of office-based visits for bipolar disorder
among physicians who participated in the National Ambulatory Care Survey between
1995-1996 and 2002-2003. They found that the number of office visits by children and
adolescents for bipolar disorder increased nearly 4000% during this time frame.
Physicians are not alone in discovering more cases of bipolar disorder. Parents and
teachers, fueled by information reported in the popular press and internet, are also
increasingly finding bipolar disorder in their students and children, respectively (McClure,
Several explanations have been put forth to account for the increased diagnosis
of bipolar disorder in children and adolescents. Blader and Carlson (2007), who
conducted the recent hospitalization study, hypothesized that the “growth in the rate of
BD-diagnosed discharges might reflect a progressive ‘re-branding’ of the same clinical
phenomenon for which hospitalized children previously received different diagnoses” (p.
112). Along this line, Carlson (1998) suggested that the increased prevalence of bipolar
disorder may be an unintended consequence of changing the diagnostic criteria for
attention-deficit hyperactivity disorder (ADHD). He noted that many of the symptoms of
pediatric bipolar disorder (e.g., affective instability, aggression) were once considered to
be symptoms associated with ADHD. However, these symptoms were subsequently
removed from the diagnostic criteria to improve diagnostic reliability. He speculated that
those who do not fit the more restricted diagnostic criteria for ADHD are being
diagnosed with bipolar disorder because a single diagnosis of ADHD fails to adequately
capture the breadth of their problems. Others have attributed the rise in the diagnosis of
bipolar disorder in children and adolescents to the availability of second-generation
antipsychotics and newer mood-stabilizers that have been shown to be effective in
treating severe irritability and aggression (e.g., Moreno et al., 2007). Because these
medications are widely prescribed and FDA-approved for adults with bipolar disorder,
perhaps physicians believe that a diagnosis of bipolar disorder is needed to justify
prescribing these medications to young people who experience severe affective and
Controversies Associated With Pediatric Bipolar Disorder
Some researchers and clinicians have welcomed the increased recognition of
pediatric bipolar disorder because of their belief that many young people with bipolar
disorder were misdiagnosed in the past and, consequently, failed to receive effective
treatment (e.g., Geller & Luby, 1997). However, others have argued that the pendulum
has swung too far in the other direction in that bipolar disorder is now being diagnosed
in many children and adolescents who do not actually have the disorder (Klein, Pine, &
Klein, 1998; Weller, Calvert, & Weller, 2003). The experts on both sides of this debate
agree that the children and adolescents who are being diagnosed with bipolar disorder
do not meet the strict diagnostic criteria for bipolar disorder in the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition, test revision (DSM-IV-TR; American
Psychiatric Association, 2000); however, they disagree as to how discrepancies from
the diagnostic criteria should be treated.
The children and adolescents who are now being diagnosed with bipolar disorder
differ from their adult counterparts in two fundamental areas: cycling patterns and
symptom presentations. In the DSM-IV-TR (American Psychiatric Association, 2000), a
manic episode is defined as an “abnormally and persistently elevated, expansive or
irritable mood” that must be present for at least one week, unless hospitalization is
required, together with three additional symptoms, such as “inflated self-esteem or
grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility,
increased involvement in goal-directed activities or psychomotor agitation, and
excessive involvement in pleasurable activities with a high potential for painful
consequences” (p. 357). Yet, the prototypical manifestation of bipolar disorder in which
an individual experiences clear-cut episodes of mania/hypomania and depression,
punctuated by periods of normal functioning, rarely occurs in children and adolescents
(Carlson, Loney, Salisbury, & Volpe, 1998). Instead, most of the young people who
receive this diagnosis experience moods shifts that change dramatically on a daily, or
even hourly, basis (Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003). In addition to
divergent cycling patterns, most of the young people diagnosed with bipolar disorder
also exhibit a different constellation of symptoms from adults with the disorder. In the
place of episodes of depression and mania/hypomania, children and adolescents
diagnosed with bipolar disorder are more likely to experience chronic affective and behavioral instability characterized by severe irritability, temper tantrums, aggressive
behavior, impulsivity, and hyperactivity (Biederman, Mick, Faraone, & Wozniak, 2004;
Hamrin & Pachler, 2007; Weckerly, 2002).
While acknowledging these discrepancies from the standard diagnostic criteria,
proponents of the pediatric bipolar designation contend that the current definition of
bipolar disorder in the DSM-IV-TR (American Psychiatric Association, 2000) is too
narrow and fails to account for how bipolar disorder is manifested differently across the
lifespan (e.g., Geller & Luby, 1997; Weller et al., 2003). They argue that although the
DSM-IV-TR formally recognizes developmental differences in the experience of
depression for children and adolescents (i.e., more irritability than sadness), it does not
acknowledge any differences in the experience of bipolar disorder for this age group.
Furthermore, it appears that the atypical manifestations of bipolar disorder experienced
by children and adolescents may not be that atypical after all (Weckerly, 2002). Like
their younger counterparts, many adults with bipolar disorder do not neatly match the
DSM-IV-TR criteria either. For example, McElroy et al. (1992) found that about 30% of
adults with bipolar disorder primarily experience mixed episodes rather than clear-cut
episodes of mania in which euphoria and grandiosity dominate. Along this line,
Youngstrom, Birmaher, and Findling (2008) make the case that the extremely rapid
cycling patterns exhibited by children and adolescents with bipolar disorder should be
classified as mixed episodes rather than ultrarapid (5-364 episodes a year) or ultradian
cycling (>365 episodes a year). Studies such as these suggest that mixed mood
episodes might be more common than the traditional manic episodes emphasized in the
DSM-IV-TR and abnormal psychology textbooks.
As already mentioned, this expanded conceptualization of bipolar disorder is not
shared by all, and opponents also have research that calls into question the validity of a
bipolar disorder diagnosis in children and adolescents (e.g., Klein et al., 1998). Severe
irritability, one of the hypothesized features of pediatric bipolar disorder, is also one of
the most controversial (Rich & Leibenluft, 2006). Although the DSM-IV-TR (American
Psychiatric Association, 2000) recognizes irritability as a symptom of mania, critics point
out that irritability is not unique to mania as it can also be a symptom of a depressive
disorder, a pervasive developmental disorder, an anxiety disorder, or even a disruptive
behavior disorder (Leibenluft et al., 2003; McClure et al., 2002; Rich & Leibenluft, 2006).
Research casts doubt on the diagnostic value of irritability in identifying a child or
adolescent with bipolar disorder. For example, Geller et al. (2002) found that irritability
was not helpful in discriminating bipolar disorder from ADHD because this symptom was
so common in both diagnostic groups. Excluding irritability from the definition of mania
or hypomania would dramatically reduce the number of children and adolescents
diagnosed with bipolar disorder. In a study conducted by Wozniak et al. (1995), 77% of
the children in their sample met criteria for bipolar disorder because of extreme
irritability, while only 5% meet criteria because of traditional symptoms of mania (e.g.,
euphoria, grandiosity). While severe irritability is a serious problem that demands
treatment, it is debatable whether bipolar disorder should be diagnosed in children and
adolescents who present with severe irritability in the absence of other traditional
Recent findings from longitudinal research raise additional concerns about the
validity of bipolar disorder diagnoses in children and adolescents. Preliminary research
indicates that many of the young people who have been diagnosed with bipolar disorder
will not carry this diagnosis into adulthood, but instead receive subsequent diagnoses of
major depressive disorder, substance use disorders, and personality disorders in
adulthood (e.g., Carlson & Meyer, 2006; Post & Kowatch, 2006; Goldstein & Levitt,
2006). Although more research is definitely needed, it seems likely that many of the
children and adolescents who are currently diagnosed with bipolar disorder will never
experience the more prototypical forms of bipolar disorder I or II in adulthood
(Youngstrom et al., 2006). Such findings raise serious questions about the hypothesized
developmental differences in the manifestation of bipolar disorder.
Additional questions about the validity of pediatric bipolar disorder arise when
clinicians attempt to distinguish bipolar disorder from other disorders with similar
presentations. Affective and behavior instability are not unique to bipolar disorder as
these symptoms are commonly associated with attention-deficit hyperactivity disorder
(ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), schizophrenia,
substance use disorders, pervasive developmental disorders, and early-onset
personality disorders (Biederman et al., 1996; Geller & Luby, 1997; Kutcher, Marton, &
Korenblum, 1990; Papolos, 2003; Weckerly, 2002). Furthermore, researchers have
found that pediatric bipolar disorder is highly co-morbid with ADHD, ODD, and CD (e.g.,
Faedda, Baldessarini, Glovinsky, & Austin, 2004; Spencer et al., 2001), which casts
further doubt as to the validity and distinctiveness of pediatric bipolar as a new
Alternative Conceptualizations of Bipolar Disorder
As this review indicates, there is currently a lack of consensus as to how to
categorize those children and adolescents who present with extreme affective and
behavioral instability in the absence of clear-cut episodes of mania or hypomania. One
side (e.g., Biederman et al., 2004) recommends expanding our conceptualization of
bipolar disorder to accommodate this clinical population, while the other side (e.g., Klein
et al., 1998) contends that these young people are experiencing problems that are too
divergent from bipolar disorder to receive the same diagnosis. Leibenluft et al. (2003)
developed a new taxonomy for this population that includes three subtypes of juvenile
mania. The first subtype, narrow phenotype, refers to those children and adolescents
who meet the conventional diagnostic criteria for mania or hypomania in the DSM-IV-TR.
The second subtype, intermediate subtype, refers to those who experience either
traditional symptoms of hypomania for less than a week [(hypo)mania not otherwise specified] or who experience discrete episodes of irritability [irritable (hypo)mania]. The
final subtype, severe mood and behavioral dysregulation, refers to those children and
adolescents who exhibit the following symptoms: irritability, high reactivity to negative
events, aggressive behavior, low frustration tolerance, and agitation. Those who fall into
this third category typically experience chronic emotional and behavioral problems
without any significant periods of normal mood or adequate psychosocial functioning.
Though still an experimental diagnosis, subsequent research has provided some
support for the validity of this third subtype. Brotman et al. (2006) used a modified
version of this subtype, which they called severe mood dysregulation, to evaluate the
nature, correlates, and developmental course of affective instability among adolescents
in the Great Smoky Mountain Community Sample. They found that 3.3% of the sample
satisfied diagnostic criteria for this new classification, which they noted exceeds the
prevalence rate for both major depressive and bipolar disorder in this age group.
Consistent with the research on pediatric bipolar disorder, the three most common co-
morbid disorders associated with this subtype were ADHD (27%), conduct disorder
(26%), and oppositional defiant disorder (25%). They also found that severe emotional
dysregulation in adolescence may be a precursor to chronic major depression in
adulthood rather than bipolar disorder. In another study, Leibenluft, Cohen, Gorrindo,
Brook, and Pine (2006) examined the longitudinal course of chronic and episodic
irritability in a sample of approximately 700 individuals who had been tracked from early
adolescence to early adulthood. They found that episodic irritability during early
adolescence predicted bipolar disorder, generalized anxiety disorder, and phobias
during late adolescence and early adulthood, whereas chronic irritability predicted
diagnoses of disruptive behavior disorders and major depressive disorder.
Medication is considered to be the first line of treatment for children and
adolescents diagnosed with bipolar disorder. Historically, lithium has been considered to
be the drug of choice for managing classical mania in adults with bipolar disorder
(Hamrin & Pachler, 2007). Given this track record, lithium subsequently gained formal
FDA approval for the treatment of mania in children and adolescents. However, this
approval was granted based on its effectiveness with adults, not from any demonstrable
effectiveness with children and adolescents with bipolar disorder (Smarty & Findling,
2007). In fact, very little evidence supports the use of lithium in treating children and
adolescents with bipolar disorder (e.g., Singh, Pfeifer, Barzman, Kowatch, & Delbello,
2007), which should not be surprising given the substantial differences in symptom
presentation and cycling patterns between young people and adults diagnosed with
The pharmacological treatment of pediatric bipolar disorder can become quite
complicated, and frequently those diagnosed with the disorder endure multiple
medication trials before finding a medication formula that works. A panel convened by
the Child and Adolescent Bipolar Foundation developed treatment guidelines for
physicians who treat children and adolescents with bipolar disorder (Kowatch et al.,
2005). For those young people who do not exhibit comorbid psychosis, the panel
recommended that treatment start with either a mood stabilizer [e.g., lithium, divalproex
acid (Depakote®), carbamazepine (Tegretol®)] or an atypical anti-psychotic [e.g.,
risperidone (Risperdal®), olanzapine (Zprexa®), clozapine (Clozaril®), quetiapine
(Seroquel®)]. Other experts have recommended treatment commence with one of the
newer, atypical anti-psychotics (Biederman et al., 2000; Mick, Biederman, Faraone,
Murray, & Wozniak, 2003), while Hamrin and Pachler (2007) suggested that
combination treatments, whether a mood stabilizer plus an atypical antipsychotic or two
mood stabilizers, hold the most promise in treating pediatric bipolar disorder.
Even after achieving some semblance of mood stabilization, many of the children
and adolescents diagnosed with bipolar disorder continue to exhibit significant
emotional and behavioral problems. Although supplementation with an antidepressant
might seem reasonable for treating depressed mood and irritability, some physicians
are concerned that the use of antidepressants, specifically the SSRI’s, may induce or at
least exacerbate emotional instability in those with pediatric bipolar disorder
(e.g.,Pavuluri & Bishop, 2007). Ghaemi, Ko, and Goodwin (2002) even suggest that the
copious use of antidepressants in the treatment of bipolar disorder may be responsible
for the increased prevalence of rapid cycling bipolar disorder. However, other experts
contend that these fears of inducing mania with SSRI’s are exaggerated, and they
suggest that many young people can experience better outcomes by judiciously
incorporating these antidepressants into their treatment plans (Rich & Leibenluft, 2006).
Similar concerns have been voiced about the use of psychostimulants in treating
comorbid ADHD. For those with both disorders, a sustained-release stimulant [e.g.,
methylphenidate (Concerta®)] may be helpful in managing symptoms of ADHD without
exacerbating irritability or aggressive behavior (Hamrin & Pachler, 2007).
Though the aforementioned medications have brought much relief to those
diagnosed with pediatric bipolar disorder and their families, several barriers limit the
effectiveness of these treatments. First, for these medications to be effective, they need
to be taken conscientiously, and regular blood tests may be needed to assure
therapeutic blood levels (Hamrin & Pachler, 2007). Because many of the parents of
these young people have similar problems themselves (e.g., inattention, emotional
instability, inadequate psychosocial functioning), medication noncompliance and
treatment dropout frequently occur (DelBello, Hanseman, Adler, Fleck, & Strakowski,
2007; Miklowitz et al., 2004). Second, many of the abovementioned medications
produce intolerable side effects. The atypical anti-psychotics may cause extrapyramidal
side effects (e.g., tremor, slurred speech, dystonia) and weight gain, while the
anticonvulsants may cause “weight gain, nausea, sedation, dizziness, tremor, headache,
visual disturbances, blood dyscrasias, elevated thyrotropin levels and alopecia [hair
loss]” (Hamrin & Pachler, 2007, p. 49). Side effects such as weight gain and hair loss
are especially problematic for adolescents who are frequently hypersensitive about their
appearance. Finally, as it stands now, the pharmacological treatment of pediatric bipolar
disorder remains more art than science. Unfortunately, many children and adolescents
diagnosed with bipolar disorder are being treated with medications that have rather
meager evidence of their effectiveness (McClure et al., 2002). Readers also should
keep in mind that this treatment literature suffers from a lack of controlled double-blind
studies, and that most of the purported benefits of these medications come from case
reports, chart reviews, and open-label trials (Smarty & Findling, 2007).
Although pharmacotherapy continues to be the first line of treatment, evidence is
beginning to accumulate that demonstrates the added value of counseling interventions
in treating pediatric bipolar disorder. One of the most useful interventions that mental
health counselors can offer young people and their families is the Family-Focused
Psychoeducational Treatment Model (Miklowitz et al., 2004), which incorporates both
psychoeducation and skills training. Counseling interventions may also be effective in
directly treating the symptoms of pediatric bipolar disorder and comorbid conditions.
McClure et al. (2002) suggested that cognitive-behavioral therapy may be helpful in
treating pediatric bipolar disorder given its track record in treating major depression and
dysthymia in this age group. Furthermore, given the hypothesized relationship between
borderline personality disorder and bipolar disorder (e.g., Paris, Gunderson, & Weinburg,
2007), interventions that have been shown to be effective in treating the former may
also be helpful in treating the later. In support of this hypothesis, one recent pilot study
found that dialectical behavior therapy was a useful adjunct to medication in the
treatment of pediatric bipolar disorder (Goldstein, Axelson, Birmaher, & Brent, 2007).
Finally, counseling interventions may also be useful in treating the comorbid disorders
that frequently accompany pediatric bipolar disorder. There are a number of empirically-
validated psychosocial interventions to treat the disruptive behavior disorders that
frequently co-occur with pediatric bipolar disorder (see Christophersen & Mortweet,
Until recently, students who exhibited severe behavior problems were likely
diagnosed with attention deficit hyperactivity disorder (ADHD), oppositional defiant
disorder (ODD), or conduct disorder. Because these three disorders can be treated
fairly well with psychosocial interventions (Kazdin, & Weisz, 2003), a referral to a non-
medical mental health professional (counselor, social worker, psychologist) would have
been a reasonable decision in these situations. However, many pediatric psychiatrists
have argued that the emotional and behavioral problems exhibited by many of these
young people reflect a fundamental mood disorder, rather than a traditional behavioral
disorder (e.g., Biederman et al., 2004). As an example of this paradigm shift, a
roundtable convened by the National Institute of Mental Health (2001) recommend the
use of bipolar disorder NOS for characterizing children and adolescents who exhibit
severe emotional and behavioral instability in the absence of clear-cut episodes of
mania or hypomania. From this framework, it is critical for school counselors to
recognize potential symptoms of pediatric or early-onset bipolar disorder so referrals will
be made for more specialized psychiatric services. Specifically, a diagnosis of pediatric
bipolar disorder has prescriptive value by suggesting treatment strategies (e.g., mood
stabilizers), which are likely to be effective for this population (Youngstrom et al., 2008).
However, not all mental health professionals have embraced this expanded
conceptualization of bipolar disorder. Other experts in childhood psychopathology
maintain that the problems experienced by these young people are too divergent from
the DSM-IV-TR criteria to justify a diagnosis of bipolar disorder. They also caution that
bipolar disorder loses its meaning if it is applied to every possible manifestation of
affective dysregulation (e.g., Klein et al., 1998). In addition to divergent symptom
presentations from adults with bipolar disorder, research on the differential diagnosis
and longitudinal course of pediatric bipolar disorder raises additional doubts as to the
validity of this hypothesized diagnostic entity. The severe mood and behavioral dysregulation subtype proposed by Leibenluft et al. (2003) may provide a more accurate
description of the emotional and behavioral problems experienced by many of those
currently diagnosed with pediatric bipolar disorder, but it has not yet been established
The treatment of severe emotional and behavioral instability in children and
adolescents, whatever label it might be given, has proven to be very challenging.
Lithium, the gold standard for managing mania in adults, has not been shown to be
effective with younger individuals. The newer, atypical anti-psychotics and
anticonvulsants appear to be effective in reducing irritability and agitation; yet, it is not
uncommon for children and adolescents to suffer through numerous medication trials
before finding some combination that works. Even when an effective combination is
found, troublesome side effects and family noncompliance may limit the effectiveness of
these treatments. Research on the effectiveness of counseling interventions in the
treatment of bipolar disorder is also quite modest. Some evidence suggests that
psychoeducation and skills-training programs are effective in helping young people and
their families cope more effectively with the disorder, while cognitive-behavioral and
dialectical behavior therapy may decrease depression and emotional instability,
respectively. Some have also endorsed the promise of early intervention programs in
reducing the negative outcomes associated with the disorder (Biederman et al., 2000;
Lewinsohn, Seeley, & Klein, 2003), but evidence of their effectiveness is basically
Research on the phenomenology and treatment of pediatric bipolar disorder is
still in its infancy. In fact, systematic studies of bipolar disorder in this population did not
commence until the 1970’s (Chang & Steiner, 2003). Fortunately, during the past 10-15
years, research on the classification and treatment of pediatric bipolar disorder has
proliferated. Given the advances made in just the last several years, there is reason to
hope that continued research efforts will lead to both more valid diagnostic
classifications and more effective treatments.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Bardick, A. D., & Bernes, K. B. (2005). A closer examination of bipolar disorder in
school-age children. Professional School Counseling, 9, 72-77.
Biederman, J., Faraone, S. V., Milberger, S., Jetton, J. G., Chen, L., Mick, E., et al.
(1996). Is childhood oppositional defiant disorder a precursor to adolescent
conduct disorder? Findings from a four-year follow-up study of children with
ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 35,
Biederman, J., Mick, E., Faraone, S. V., Spencer, T., Wilens, T. E., & Wozniak, J.
(2000). Pediatric mania: A developmental subtype of bipolar disorder. Biological
Biederman, J., Mick, E., Faraone, S. V., & Wozniak, J. (2004). Pediatric bipolar disorder
or disruptive behavior disorder? Primary Psychiatry, 11, 36-41.
Blader, J. C., & Carlson, G. A. (2007). Increased rates of bipolar disorder diagnoses
among U.S. child, adolescent, and adult inpatients, 1996-2004. Biological
Brotman, M. A., Schmajuk, M., Rich, B. A., Dickstein, D. P., Guyer, A. E., Costello, E. J.,
et al. (2006). Prevalence, clinical correlates, and longitudinal course of severe
mood dysregulation in children. Biological Psychiatry, 60, 991-997.
Carlson, G. A. (1990). Child and adolescent mania—diagnostic considerations. Journal of Child Psychology and Psychiatry, 31, 331-341.
Carlson, G. A. (1998). Mania and ADHD: Comorbidity or confusion. Journal of Affective
Carlson, G. A., Loney, J., Salisbury, H., & Volpe, R. J. (1998). Young referred boys with
DICA-P manic symptoms vs. two comparison groups. Journal of Affective
Carlson, G. A., & Meyer, S. E. (2006). Phenomenology and diagnosis of bipolar disorder
in children, adolescents, and adults: Complexities and developmental issues.
Development and Psychopathology, 18, 939-969.
Chang, K., & Steiner, H. (2003). Offspring studies in child and early adolescent bipolar
disorder. In B. Geller & M. P. Delbello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 107-129). New York: Guilford.
Christophersen, E. R., & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington,
DelBello, M. P., Hanseman, D., Adler, C. M., Fleck, D. E., & Strakowski, S. M. (2007).
Twelve-month outcome of adolescents with bipolar disorder following first
hospitalization for a manic or mixed episode. American Journal of Psychiatry,
Faedda, G. L., Baldessarini, R. J., Glovinsky, I. P., & Austin, N. B. (2004). Pediatric
bipolar disorder: Phenomenology and course of illness. Bipolar Disorders, 6, 305-
Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past
10 years. Journal of the American Academy of Child and Adolescent Psychiatry,
Geller, B., Zimerman, B., Williams, M., DelBello, M. P., Bolhofner, K., Craney, J. L., et al.
(2002). DSM-IV mania symptoms in a prepubertal and early adolescent bipolar
disorder phenotype compared to attention-deficit hyperactive and normal controls.
Journal of Child and Adolescent Psychopharmacology, 12, 11-15.
Geroski, A. M., Rodgers, K. A., & Breen, D. T. (1997). Using the DSM-IV to enhance
collaboration among school counselors, clinical counselors, and primary care
physicians. Journal of Counseling and Development, 75, 231-239.
Ghaemi, S. N., Ko, J. Y., & Goodwin, F. K. (2002). “Cade’s disease” and beyond:
Misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum
disorder. Canadian Journal of Psychiatry, 47, 125-134.
Goldstein, B. I., & Levitt, A. J. (2006). Further evidence for a developmental subtype of
bipolar disorder defined by age of onset: Results from the National Epidemiologic
Survey on Alcohol and Related Conditions. American Journal of Psychiatry, 163,
Goldstein, T. R., Axelson, D. A., Birmaher, B., & Brent, D. A. (2007). Dialectical
behavior therapy for adolescents with bipolar disorder: A 1-year open trial.
Journal of the American Academy of Child and Adolescent Psychiatry, 46, 820-
Hamrin, V., & Pachler, M. (2007). Pediatric bipolar disorder: Evidence-based
psychopharmacological treatments. Journal of Child and Adolescent Psychiatric
Kazdin, A. E., & Weisz, J. R. (Eds.). (2003). Evidence-based psychotherapies for children and adolescents. New York: Guilford.
Klein, R. G., Pine, D. S., & Klein, D. F. (1998). Negative. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1093-1096.
Kosten, T. R., & Kosten, T. A. (2004). New medication strategies for comorbid
substance use and bipolar affective disorders. Biological Psychiatry, 56, 771-777.
Kutcher, S. P., Marton, P., & Korenblum, M. (1990). Adolescent bipolar illness and
personality disorder. Journal of the American Academy of Child and Adolescent
Leibenluft, E., Charney, D. S., Towbin, K. E., Bhangoo, R. K., & Pine, D. S. (2003).
Defining clinical phenotypes of juvenile mania. American Journal of Psychiatry,
Leibenluft, E., Cohen, P., Gorrindo, T., Brook, J. S., & Pine, D. S. (2006). Chronic
versus episodic irritability in youth: A community-based, longitudinal study of
clinical and diagnostic associations. Journal of Child and Adolescent
Lewinsohn, P. M., Seeley, J. R., & Klein, D. N. (2003). Bipolar disorder in adolescents:
Epidemiology and suicidal behavior. In B. Geller & M. P. Delbello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 7-24). New York: Guilford.
Mick, E., Biederman, J., Faraone, S. V., Murray, K., & Wozniak, J. (2003). Defining a
developmental subtype of bipolar disorder in a sample of nonreferred adults by
age of onset. Journal of Child and Adolescent Psychopharmacology, 13, 453-462.
Miklowitz, D. J., George, E. L., Axelson, D. A., Kim, E. Y., Birmaher, B., Schneck, C., et
al. (2004). Family-focused treatment for adolescents with bipolar disorder.
Journal of Affective Disorders, 82, 113-128.
McClure, E. B., Kubiszyn, T., & Kaslow, N. J. (2002). Advances in the diagnosis and
treatment of childhood mood disorders. Professional Psychology: Research and
McElroy, S. L., Keck, P. E., Pope, Jr., H. G., Hudson, J. I., Faedda, G. L., & Swann, A.
C.(1992). Clinical and research implications of the diagnosis of dysphoric or
mixed mania or hypomania. American Journal of Psychiatry, 149, 1633-1644.
Moreno, C., Laje, G., Blanco, C., Jiang, H. Schmidt, A. B., & Olfson, M. (2007). National
trends in the outpatient diagnosis and treatment of bipolar disorder in youth.
Archives of General Psychiatry, 64, 1032-1039.
National Institute of Mental Health. (2001). National Institute of Mental Health research
roundtable on prepubertal bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 871-878.
Papolos, D. F. (2003). Bipolar disorder and comorbid disorders: The case for a
dimensional nosology. In B. Geller & M. P. Delbello (Eds.), Bipolar disorder in childhood and early adolescence (pp. 76-106). New York: Guilford.
Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline
personality disorder and bipolar spectrum disorders. Comprehensive Psychiatry,
Pavuluri, M., & Bishop, J. R. (2007). Pediatric bipolar disorder: Translation of research
findings to clinical practice. Current Medical Literature: Pediatrics, 20, 57-68.
Post, R. M., & Kowatch, R. A. (2006). The health care crisis of childhood-onset bipolar
illness: Some recommendations for its amelioration. Journal of Clinical Psychiatry,
Rich, B. A., & Leibenluft, E. (2006). Irritability in pediatric mania. Clinical
Ritchie, M. H., & Partin, R. L. (1994). Referral practices of school counselors. School
Singh, M. K., Pfeifer, J. C., Barzman, D., Kowatch, R. A., & Delbello, M. P. (2007).
Pharmacotherapy for child and adolescent mood disorder. Psychiatric Annals,37,
Smarty, S., & Findling, R. L. (2007). Psychopharmacology of pediatric bipolar disorder:
A review. Psychopharmacology, 191, 39-54.
Spencer, T. J., Biederman, J., Wozniak, J., Faraone, S. V., Wilens, T. E., & Mick, E.
(2001). Parsing pediatric bipolar disorder from its associated comorbidity with the
disruptive behavior disorders. Biological Psychiatry, 49, 1062-1069.
Weckerly, J. (2002). Pediatric bipolar mood disorder. Developmental and Behavioral
Weller, E. B., Calvert, S. M., & Weller, R. A. (2003). Bipolar disorder in children and
adolescents: Diagnosis and treatment. Current Opinion in Psychiatry, 16, 383-
Wozniak, J., Biederman, J., Kiely, K., Ablon, J. S., Faraone, S. V., Mundy, E., et al.
(1995). Mania-like symptoms suggestive of childhood-onset bipolar disorder in
clinically referred children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 867-876.
Youngstrom, E. A., Birmaher, B., & Findling, R. L. (2008). Pediatric bipolar disorder:
Validity, phenomenology, and recommendations for diagnosis. Bipolar Disorders,
Youngstrom, E., Meyers, O., Youngstrom, J. K., Calabrese, J. R., & Findling, R. L.
(2006). Diagnostic and measurement issues in the assessment of pediatric
bipolar disorder: Implications for understanding mood disorder across the life
cycle. Development and Psychopathology, 18, 989-1021.
Direct correspondence to Greg Hatchett, Department of Counseling, Human
Services, and Social Work, Northern Kentucky University, Highland Heights, KY 41099,
or email at [email protected] Hatchett is an assistant professor in the
Department of Counseling, Human Services, and Social Work at Northern Kentucky
University. He teaches courses in the counselor education program in the areas of
assessment, diagnosis, and clinical interventions. Outside of his university
responsibilities, he provides supervision to a counselor at a foster care agency, and he
is a consultant to the Northern Kentucky Regional Mental Health Court.
DE VIJF R’S: BEDOELD VOOR ROKERS DIE OP DIT MOMENT NIET BEREID ZIJN SAMENVATTING RICHTLIJN BEHANDELING VAN EEN STOPPOGING TE ONDERNEMEN TABAKSVERSLAVING (ACTuALISERING 2009) Relevance (relevantie): Vertel de roker waarom het zo belangrijk is om te stoppen, zo persoonlijk mogelijk. Risks (risico’s): Vraag de roker naar de risico’s van roken en bespreekt deze. Met jaar
Changes in posterior corneal elevation after laserDiego Vicente, Thomas E. Clinch, MD, Paul C. Kang, MDPURPOSE: To evaluate changes in posterior corneal elevation using the Pentacam topographer(Oculus) in patients having laser in situ keratomileusis (LASIK) enhancement. SETTING: Private practice, Chevy Chase, Maryland, USA. METHODS: The Pentacam device was used to evaluate the changes in poste