Studies of Brain Function and Course of Illness in Pediatric Bipolar Disorder

Objective: Irritability is a common and impairing clinical presentation in youth. Despite its significant public health impact, the clinical course and pathophysiology of irritability remains poorly understood. Chronic and severe irritability is the primary symptom of the new DSM-5 diagnosis, disruptive mood dysregulation disorder (DMDD), is an associated symptom of other pediatric disorders including Attention-Deficit/Hyperactivity Disorder (ADHD), and can be a clinical precursor to Major Depressive Disorder (MDD) and anxiety disorders. In addition, irritability is a trait distributed continuously in youth, thereby fitting well within the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) initiative. Clinically impairing irritability in children and adolescents began to gain more attention as interest grew in the diagnosis of pediatric bipolar disorder. Beginning in the 1990s, child psychiatry researchers suggested that while pediatric bipolar disorder can present with distinct episodes of mania or hypomania as in adults, the more typical pediatric presentation was chronic, severe irritability and hyperarousal symptoms. However, data collected under this protocol comprise a series of longitudinal, family, behavioral, and pathophysiological studies that differentiated classically defined episodic pediatric bipolar disorder from chronic irritability without distinct manic or hypomanic episodes. These findings are consistent with reports from other groups and meta-analyses. Among the several strands of research designed to differentiate pediatric bipolar disorder from chronic irritability, longitudinal studies provide the strongest evidence that these two phenotypes are distinct. Children with chronic irritability are at elevated risk for later depression, but not manic episodes. Thus, youth with MDD (with and without prior DMDD) are an important comparison group to explore, and we are examining the developmental trajectory, phenomenology, behavioral correlates, and underlying neural mechanisms of chronic irritability and MDD in youth. Further, because irritability and ADHD symptoms are highly comorbid in youth, participants with ADHD are an important comparison group in our work on irritability. The current translational model of irritability emphasizes the role of abnormal threat and reward processing, but also underlines the relevance of environmental factors in the emergence and maintenance of irritability. More precisely, it is assumed that irritable children experience environments, where rewards and punishments are inconsistently delivered leading to unintentional reinforcement of disruptive behavior through the parents. Reasons for this inconsistent parent behavior could be manifold spanning instrumental learning deficits and exaggerated responses to threat and frustrative non-reward in the parents themselves as well as lack of knowledge regarding learning principles and increased levels of stress. These factors might contribute to instrumental-learning deficits in the children increasing frequency and intensity of temper outbursts. Heightened levels of chronic irritability, another symptom of DMDD, might be more associated with features of the parent-child interaction. There is a rich literature within the framework of attachment theory showing that behavior of children with anxious-resistant insecure attachment is characterized by a general angry tone and is also associated with increased amygdala responses to negative social scenes. In addition, it was also shown that highly irritable infants are less sociable in terms of being less responsive and more fearful towards others and displaying an angry emotional tone in general as toddlers when they had been insecurely attached and more sociable when they had been securely attached. Adding another layer of complexity, it is also conceivable that inconsistent parent behavior diminishes parent's perceived trustworthiness. This could be of relevance as recent studies showed that persons are less willing to delay rewards - an action bound to increase levels of frustration - if their interaction partner is perceived as little reliable. The overall goal is to gain a clearer understanding of the environmental factors contributing to irritability in order to inform treatment and improve the outcome for children. As part of this overall goal, we plan to collect information on numerous environmental factors. First, we plan to investigate parents of youth with DMDD enrolled in this study and subthreshold DMDD enrolled in this study in order to determine clinical, behavioral, neuropsychological, neurophysiological and neuroanatomical features of the parents that contribute to the symptomatology in the children and adolescents. Further, we plan to examine parent-child interaction and its influence on irritability observed in the youth. Second, we plan to investigate the role of environmental stressors on youth's irritability symptoms. Study population: There are 6 separate populations being studied in this protocol: 1. Children and adolescents between the ages of 7-17 years old who meet criteria for DMDD or subthreshold DMDD. 2. Caregivers of children and adolescents, who meet criteria for DMDD or subthreshold DMDD and are enrolled in 02-M-0021, and are 25-85 years old will be studied. 3. Healthy volunteer children and adolescents between the ages of 7-17 years old. 4. Healthy volunteer adults between the ages of 18-25 years old. 5. Children and adolescents between the ages of 11-17 years old who meet criteria for major depressive disorder (MDD). 6. Children and adolescents between the ages of 8-17 years who meet criteria for attention-deficit/hyperactivity disorder (ADHD) who do not have a mood disorder. Design: For children and adolescents with full or subthreshold DMDD, ADHD, and/or MDD, this study is an outpatient characterization and longitudinal follow-along design. Once determined to be eligible, individuals come for an initial assessment, and then return at varying intervals until age 25 for clinical interviews, behavioral tasks, structural and functional MRI, magnetoencephalography (MEG)/electroencephalography (EEG), and functional near-infrared spectroscopy (fNIRS). For healthy volunteer children and adults this study is an outpatient cross-sectional study that includes clinical interviews, behavioral tasks, structural and functional MRI, magnetoencephalography (MEG)/electroencephalography (EEG), and functional near-infrared spectroscopy (fNIRS). Outcome measures: There are two primary outcome measures. First, this study will examine associations between irritability and clinical, behavioral, genetic, neuroanatomical, and neurophysiological variables in individuals with full or subthreshold DMDD and/or MDD, ADHD, anxiety, and healthy volunteers. Second, this study will examine between-group differences in clinical, behavioral, genetic, neuroanatomical, and neurophysiological variables in individuals with full or subthreshold DMDD and/or MDD, ADHD, anxiety, and healthy volunteers.