It isIt illegal to post this copyrighted PDF on any website. Bethesda, MD 20814 ([email protected]) 5415 Ste 201-B, Ln, WCedar Network, Collaborative * Baltimore, Maryland Hopkins Hospital/Bloomberg Children’s Center, Prim Care Companion CNSDisord 2017;19(4):17r02122 For [email protected]. reprints orpermissions, contact ♦ c b a © Copyright 2017Physicians Postgraduate Press, Inc. https://doi.org/10.4088/PCC.17r02122 2017;19(4):17r02122 Prim Care Companion CNSDisord guide clinicaltherapeutics. children lessthan10years ofageto better need for comparative effectiveness data in current casealsohighlights thegreat unmet prospective monitoring appearsessential. The young childrenin very asillustrated here, course ofmanyhighly fluctuating symptoms response ofthechildto treatment. Given the visualize course and ofsymptom fluctuations systematic longitudinal ratings to helpbetter their introduction. We encourage theuseof treatment optionsandapossiblesequence for or . We arange describe ofother remained inadequately responsive to Board–approved protocol. This 9-year-old girl Review Institutional under aJohnsHopkins basisintheChildNetwork plotted onaweekly behavior, andmaniaare rated by aparent and disorder,deficit/hyperactivity oppositional symptoms ofdepression, anxiety, attention- rarely utilized. We present apatient whose for ofsymptoms longitudinalare tracking systematic database, clinicaltrial andsystems are notadequately orbasedona described multisymptomatic childwithbipolardisorder Treatment sequences for the M.Post, MD Robert How to Track and Treatment Sequence A Multisymptomatic With Child Bipolar Disorder: Study Case Maryland Washington, DC Medicine, of School University Washington George ABSTRACT Division of Child and Adolescent Psychiatry, Johns Johns Psychiatry, Adolescent and Child of Division Department of Psychiatry and Behavioral Sciences, Sciences, Behavioral and Psychiatry of Department Bipolar Collaborative Bethesda, Network, Corresponding author: Robert M. Post, MD, Bipolar MD, Bipolar Post, M. Robert a,b, * ; Michael Rowe, PhD; Michael . b C ; DanaKaplan, MPH DSM-5, dysphoric dysregulation mood disorder. of dysregulation severe mood and its relative close recently to added the debate and diagnoses disagreementthe about and frequency the of specificity opinion extrapolated from controlled studies inadults and is largely on expert based studies allow children under age 10to enter, and most information is adequatelybeen studied or elucidated. Few controlled or industry-supported bipolarnews.org ratings of 5symptom domains available for Network Child inthe free (www. and illustrate unique the advantages of more regular (weekly) prospective to-treat child with acomplex, multifaceted presentationbipolar disorder of about adialogue begin treatment alternatives and sequences for difficult- the of We dysfunction scale. present current the description case inorder to degree of1-year) symptomatology retrospectivethe ratings of on a severity measuressectional of psychopathology (usually 6-month or periodic to symptomatic as much as two-thirds of of time the follow-up. outpatients course on tend adifficult prospective to run follow-up, remaining multifaceted, and accompanied by multiple comorbidities. inpatients Both and States compared to European children. young in illness very children,presentationbipolar spectrum of I disorder (BP-I). Yet, is most the bipolar common specified not otherwise bipolar disorder than inadulthood inchildhood adversethis course is related to amore presentation seriousand difficult of once bipolar has illness emerged, common precursors to BP-I and BP-II and diagnoses frequent comorbidities hyperactivity disorder (ADHD), and disruptive behavior disorders are was superiordrug to lithium- the combination). phase and inasecond combination phase (ie, risperidone plus either other risperidone over lithium both and valproate in first the both monotherapy patientsbipolar whereinmixed foundspectrum group they superiority of of inadequate treatment by etal Geller children are rarely systematically studied. One notable exception is study the among clinicians, as well as amuch-neededtreatment round new studies. of literature,in the we help hope discussion this will engender dialogue anew helpful of to child. child type this Given of systematic dearth this the studies of speculate about what treatments, of all are which off-label, might more be that treatments these remain speculative and perhaps controversial. We then multisymptomatic child with bipolar disorder with awareness the and caveat approaches disorders to these have not defined. also been syndromes are associated with considerable dysfunction, therapeutic the The therapeutic approaches to bipolar childhood-onset have illness not Most longitudinal follow-up is accomplished with either repeated cross- Complicating picture the are findings the that anxiety, attention-deficit/ Given deficitsliterature, inthe these we treatment discuss options for the episodes ofepisodes pure mania or depression, but more often fluctuating, is highly bipolarhildhood-onset disorder is rarely characterized by distinct 10,11 aimed almost entirely towardbipolar children with adiagnosis of 12 assessing randomized lithium, valproate, or risperidone in a ; click on Network). Child c 6 ; and Robert L.Findling, MD; andRobert is unknown. © 2017Copyright Physicians Postgraduate Press, Inc. 2,13–15 particularly inchildren particularly United inthe 16,17 In addition, there is considerable 7 as opposed to delayed c 18 Although latter these 1–6 How much of 3 and these

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You are prohibited from making this PDF publicly available. Clinical Points parent could print out is similar to that illustrated inFigure year. completed degree of with ahigh consistency for almost 1 5 symptom domains, which take just a few minutes, were 15–20 minutes to complete. the Then, weekly the ratings of symptoma detailed checklist, eachof about take which child maythe have already received community), inthe and demographics questionnaire includes (which what diagnoses informed consent for into entry naturalistic this study, a response to treatment. or physician to more evaluate easily symptom course and longitudinal ratings and bring to atreating these clinician Network is ability the of parents to print out weekly the Child the and Akey element behavioralmood difficulties. of were currentlythey asymptomatic or already experiencing indicated, and and sideeffects tolerability are rated. Post etal e2 For [email protected]. reprints orpermissions, contact ♦ mania. depression, anxiety, ADHD, oppositional behavior, and receive e-mails each Sunday of severity for the ratings of form and amore symptom detailed checklist and then consent,background/demographics parents out fill abrief Hopkins Institutional Board. After an informed Review under auspices the of a protocol approved by Johns the years to rate child their on aweekly basis on website asecure andillness response of or response inadequacy to treatment. weekly ratingsthe in describing course the of utilitythe of lithium, risperidone, guanfacine, or melatonin. We illustrate behavior, and mania) had who not adequately responded to (including anxiety, depression, ADHD, oppositional a complex presentation of multiple symptom domains METHODS It isIt illegal to post this copyrighted PDF on any website. ■ ■ ■ The longitudinal chart of the weekly ratingsThe longitudinalthe that the chart of In current the patient’s the case, father completed the Parents could enter children into Network Child the if The Child NetworkThe Child enlists parents of children aged 2–12 Here, we present study a case of a9-year-old with girl ■ ■ ■

symptom course anddegree ofimprovement. physicians inagraphic format for easeofvisualization of and presenting theseandthetreatments employed to disorder,hyperactivity oppositionalbehavior, andmania symptoms ofanxiety, depression, attention-deficit/ bipolarnews.org) andrating basistheirchild’s onaweekly to physicians by (at joiningtheChildNetwork www. Parents canprovide ofinputandfeedback thistype optimal therapeutic regimen. an building canbeamosthelpfulwayinterventions of child’s response to pharmacologic andpsychosocial individual the to adetailedlongitudinal record of a systematic literature to guidetherapeutics, access Given thiscomplexityofpresentation of andpaucity associated withdysfunction. haveoften multiplecomorbidities andsymptoms Children withbipolardisorders andrelated conditions 19 Pharmacologic or treatments psychosocial are present, 1 behavior, and mania graphed has been as rated as 0 symptomsthe of anxiety, depression, ADHD, oppositional of presentation weekly ratingsthe of for of journal. the Each for modified clarity figure has1, but been the format the of of BP-I considerable (DSM-5 illness experienced ). She also patient would now most likely criteria meet for adiagnosis andOctober November 2015), it would appear that this CourseIllness and symptom detailed (2)the checklist. entirelythen consistent with community (1)the diagnoses oppositional behavior, and mania illustrated inFigure 1were prospective weekly ratings of anxiety, depression, ADHD, 21 of 24, and disruptive behavioral disorder 19 of 40. (3) The was scored 15of amaximum of 52,anxiety 24of 32,ADHD hypomania lasting at least 4days, was positive. Depression 47 of amaximum score of 68,and adescription of BP-II, ie, 2 previousthe weeks. For example, mania items were scored behaviors and symptoms that in child had the experienced corresponded well parental with detailed (2)the checklist of community obtained from demographics the questionnaire compulsive disorder. (1)retrospective These inthe diagnoses school phobia, generalized anxiety disorder, and obsessive- having BP-II and 3anxiety disorder comorbidities, including community, patient the previously had been as diagnosed depression ratings, and an exacerbation in ADHD symptoms. littlemild), change in moderate but fluctuating highly improvement in mania (from mostly moderate to mostly 1.7mg/d) inJunedose 2016appeared to result insome moderate range severity (not illustrated). and weekly ratings of overall remained illness largely inthe generally also less severe from 2015 to July December 2016, moderate depression re-emerged inApril was 2016.Anxiety fromduring November period the 2015to March 2016,and (up to a day), 9,800 ug twice oppositional behavior worsened 1 mg/d). However, despite continued treatment with lithium with previously the guanfacine started 1mg/d and melatonin orotatelithium introductionthe of (4,800ugincombination depression, and ADHD initially appeared to improve with obtained. consent for weekly symptoms publicationthe was of tohave maintain modified been anonymity, and informed therapyfamily-focused and and home special schooling. are not illustrated here, althoughincluded they intermittent different psychotherapies that were employed were rated, but and are doses their plotted above symptoms, the the while usual family, or educational social, roles. treatments Drug degree of dysfunction that was associated with child’s the RESULTS Given 6 the weeks of moderate to severe mania (in The patient’s in 3 ways. diagnosis was assessed In the The switch from lithium to risperidone (maximum As illustrated inFigure 1,many weeks of severe mania, demographic and girl case the attributesthe this of All of © 2017Copyright Physicians Postgraduate Press, Inc. Prim Care Companion CNSDisord 2017;19(4):17r02122 = mild, 2moderate, and 3 = severe based on thesevere based = not

You are prohibited from making this PDF publicly available. Figure 1. Longitudinal Chart of the Child’sthe Figure of 1.Longitudinal Chart Weekly Ratings That theParent Could Print Prim Care Companion CNSDisord 2017;19(4):17r02122 For [email protected]. reprints orpermissions, contact ♦ It isIt illegal to post this copyrighted PDF on any website. 911 uanacine 1mg Seerity Score Melatonin 1mg 2 1

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You are prohibited from making this PDF publicly available. Figure 1 (continued). Longitudinal Chart of the Child’sthe Figure 1(continued). of Longitudinal Chart Weekly Ratings That theParent Could Print Post etal e4 For [email protected]. reprints orpermissions, contact ♦ responses individual child is of tothe treatmentthe great of with multiple of types symptomatology, careful assessment of systematic approach to therapeutics young of very children Symptoms to Achieve Remission Treatment for Options Targeting persistently quite symptomatic. initially to generally moderate ratings, but she has remained moving from generally severe ratings inmultiple domains improved slightly during 9to the 10months of ratings, oppositional behavior didimprove. child had the Overall, amelioratedfurther with switch the to risperidone, although symptoms and depression worsened, and were these not and anxious symptoms, but on lithium orotate, ADHD (suggestive of acomorbid oppositional defiant disorder). ADHD, and persisting moderate oppositional behavior depression (suggesting presence the of mixed mania), other moderate to severe symptoms, including anxiety, a DISCUSSION It isIt illegal to post this copyrighted PDF on any website. Format of the figure has been modified for clarity of presentation for the journal. Each of the weekly ratings of the symptoms ofanxiety,the depression, ratings weekly of the figure hasbeenmodifiedforofpresentation clarity the for thejournal.Format Eachof of therapy andspecial andhomeschooling. are plotted above thesymptoms. While thedifferent psychotherapies that were employed were rated, althoughtheyincludedintermittent familyfocused 3 disorderattention-deficit/hyperactivity (ADHD), oppositionalbehavior, andmaniahasbeengraphed asrated as0 = Given paucity the of data literature inthe to guidea Lithium orotate appeared to initially help manic, ADHD, severe basedonthedegree that was ofdysfunction associated withthechild’s usualfamily, social, oreducational roles. Drugtreatments andtheirdoses

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1 PP I 2 1 I Da under 10 years of age; so, all of the suggestionsunder 10yearsthe are of age; off-label. so, of all AdministrationDrug (FDA) approval for inchildren use to Maximize Antimanic Effects StabilizersMood andAtypical Antipsychotics therapy approach. may most the fruitful be and combined of use medications and family education and complex combination treatment may often necessary; be as supplemented by nutraceuticals; recognizing that targeting residual symptoms with appropriate medications with greatest the drugs tolerability additionally and safety; stabilization prior to of use ADHD medications; choosing multisymptomatic such cases as one the we have illustrated. strategies and sequences that employed could be incomplex physician. The following is adiscussion of possible treatment Network is likely of to be great assistance to treating the systematized and available from parental ratings Child inthe treatments andthe tolerability givenobserved, that is of parents about course of symptoms, degree of improvement importance. Having and detailed frequent feedback from 1 t e None of the options hereNonethe discussed have of USFood and The general treatment goals would include mood I

© 2017Copyright Physicians Postgraduate Press, Inc. 1 Prim Care Companion CNSDisord 2017;19(4):17r02122 1 I 4 1 1 1 1 = not present, 1 a 1 1 7 = 1 mild, 2moderate, and 1

You are prohibited from making this PDF publicly available. al, more than effective monotherapy study inthe by et Geller to risperidone,lithium as combinations addback of the were lack asystematic database. bipolar disorder are literature inthe poorly described and algorithms for inadequately the responsive young child with nonexistent) rationale forthe The section. this that of is part supportingevidence from them moderately strong to almost itfact, islarge this array of diverse options (with arange of study by Kowatch etal. stabilizersmood (lithium, , valproate) inthe Findling etal. many patients needing stimulants) also studies inthe by were more also effective than either monotherapy (with difficulties that have does supportdifficulties evidentiary studies inchildren with bipolarthese paucity disorder. of the here use little of because placebo-controlled is of trial clinical medicine of apositivein evidence-based randomized larger database. larger lithium orotate to lithium for there which is a such as risperidone. This might include switch the from Prim Care Companion CNSDisord 2017;19(4):17r02122 For [email protected]. reprints orpermissions, contact ♦ of etal Scheffer agonist guanfacine. This would supported be by data the regimenthe that already includes noradrenergicthe α to possible the utilityspeaks of adding astimulant to Targeting ADHD many other investigators might in field the suggest. awarenessfull that may they differ from radically what Furthermore, the authors list their suggestions with the mood stabilization,mood anxiety symptoms usually diminish aged 13–17 and not in preteens aged 10–12). With better a controlled study favorable than stimulants effects alone. combination of astimulant and guanfacine may have more ADHD symptoms not does exacerbate mania and that the open data in adolescents with bipolar depression anxiety (rather disorders), than mood and it has positive have and history apersonal positive family of history effectiveparticularly in adults with bipolar disorder who appears lamotrigine. addition further of the patientthis on lithium and risperidone, we would consider bipolar disorder. With inadequate stabilization mood of stabilizing and antianxiety at effects least in adults with lamotrigine, and valproate) each have considerable mood- StabilizationMood andAntianxiety Effects Approaches toOther stabilization was achieved. child,in this stimulants deferred could be until better mood inadequate response to lithium-risperidone the combination but not of doses stimulants. high, Thus, faceof inthe an stabilizationmood first prior to using low to moderate, consensus that field inthe one should achieve adequate It isIt illegal to post this copyrighted PDF on any website. 12 Nonetheless, one potential approach to patient’s this Increasing of severity ADHD despite improving mania The stabilizers mood (carbamazepine, especially when they involved they when especially an 24 Most combinations children needed also of 26 23 that stimulant augmentation for residual Combinations of lithium and valproate valproate and lithium of Combinations 29 of maintenance (but only inteenagers 25 11,21 The traditional gold standard 27 There is general 22 would be 28 and in 20 In In 2

children depression. has antimanic inadults effects and is indicated as an adjunct to antidepressants inunipolar inbipolar tofailed show depression efficacy inadults, it of dopamine its agonist partial properties. While to substantial, but aripiprazole prolactin decreases because aged 13–17years old with bipolar depression. exhibited significant highly antidepressant inchildren effects showing that compared to placebo, (20–80mg/d) been studied inmania,been etal but DelBello and Lurasidone no other metabolic sideeffects. has not that of risperidone, lurasidone has little weight gain liability and weight the while gain of is about to equal depression in adults, but neither is approved for children, for an anticholinergic. gain, and extrapyramidal with potential the side effects need as much about risperidone’s prolactin elevations, weight forto doses higher antimanic without effects having to worry antianxiety This might open up effects. also ability the to go child to another atypical with better antidepressant and depression inadults suggest possibility the of switching this that risperidone is not FDA approved for unipolar or bipolar and prolactin elevations. findings along These with fact the than lithiumeffects or valproate, including more weight gain of mood disordersof mood with bipolar disorder have who anegative family history (aged 13–18). patients (aged 7–12) as opposed to older the adolescents mania were negative, youngest inthe placebo didexceed they While overall the results of inchildhood predicted by apositive family disorder). of history mood delays with aloss of some 9IQ points on average. otherbifida, major malformations, and major development pregnant, triple the liabilities fetus for exposed of the spinal syndrome, and, inwomen of age child-bearing become who development of irregularities, menstrual ovarian polycystic anxiety inyoung children with bipolar disorder. preference of to use the antidepressants for depression and concomitantly, and we would pursue strategies these in positive data with oxcarbazepine inyounger children, are stronger for carbamazepine than oxcarbazepine, given data for its antimanic and antidepressant in adults effects Better Tolerability andAntidepressant Efficacy AlternativeOther Atypical Antipsychotics: Aiming for careful consideration.deserve P450 3A4compared to carbamazepine, oxcarbazepine might ininducing effects minimal hepatic enzymes cytochrome lower incidence of severe white count suppression, and its and reduce daytime and sideeffects sedation. that would allow for nighttime all dosing to help with sleep carbamazepine and oxcarbazepine (Equetro and Oxtellar) In children, weight gain on aripiprazole minimal can be Quetiapine and lurasidone are approved for bipolar Carbamazepine appears more to be effective in adults Valproate the is less desirable in females of because In study the by etal, Geller © 2017Copyright Physicians Postgraduate Press, Inc. 36 and has the advantage of being relatively and has advantage the being weight of Sequencing Sequencing Treatment inaMultisymptomatic Child 32 There are long-acting preparationsboth of 19,31 (incontrast to lithium response 12 risperidone had more side 35 presented data 33,34 Although 30

32 the the e5

You are prohibited from making this PDF publicly available. symptoms patient. inthis seen merit adjunctive combined inthe use depression and ADHD Post etal e6 For [email protected]. reprints orpermissions, contact ♦ depression support for of use the omega-3 fatty acids to target slowly on aweekly basis to 2,000to 2,700mg/d. stores, and of doses 500mg aday twice usually are increased N pathological habits and addictions. compulsive disorder, and helps of variety awide decrease serotoninselective reuptake inhibitors (SSRIs) inobsessive- bipolar depression, is helpful inpotentiating of effects the which has positive placebo-controlled data in adults with and depression would addition the be of N-acetylcysteine, stabilizer.mood An excellent option for residual anxiety to combination the of an atypical, lithium, and another as that inFigure seen 1,we would of adjuncts addaseries Anxiety, andOppositionality Nutriceutical Approaches to Depression, depression. each in bipolar depression and as an adjunct in unipolar neutral, and recent data but open designs. relative using randomized trials clinical with practical ease Parenthetically,needed. accomplished could this be with antipsychotics inchildren with bipolar disorder is sorely comparative atypical and studiesthe tolerability of efficacy of a stimulant as noted added could be then previously. symptoms of ADHD and oppositional behavior remaining, and anxietymood response, but substantial residual and has positive placebo-controlled data in1of 2studies is FDA approved for schizophrenia and mania and as an adjunct to antidepressants inunipolar depression. to aripiprazole. Brexpiprazole is approved for schizophrenia FDAthe approval of 2dopamine agonists partial inaddition trial to quetiapine even though it inaplacebo-controlled failed ofuse melatonin), one might instead consider switch the were compounded with continued insomnia (despite the addition of aripiprazole instead. If anxiety and depression or ziprasidone, another while (R.L.F.) would consider the author (R.M.P.) would switch risperidone to lurasidone schizophrenia. adults successfullyand in childhood-onset used has been highest rate of antimanic response among atypicals the in count monitoring with . Yet, clozapine has the other atypicalsthe and for need the most weekly of white propensitytheir for of because weight gain greater than adjunct inadults with mixed depression. monotherapy placebo-controlled studies inchildren with autism either in and utility on irritability inchildren is documented by 3 It isIt illegal to post this copyrighted PDF on any website. -acetylcysteine is without sold -acetylcysteine aprescription food in health Although data the are not unequivocal, there is some With some, but incomplete, degrees of improvement, such From uncertainties the noted previously, conduct the of If the child considerabledeveloped the weight gain,If one and clozapine are relatively to be avoided 38

of childhood bipolar of childhood depression. With an excellent 47 and ADHD. 44 or in2others as an adjunct to risperidone. 39 This need is now further magnified by is This now magnified need further 37 48 indicate its effectiveness as an Because of its Because safety, it may 49 19,41–43 Its tolerability 45,46 40

help prodromal identify symptoms and syndromes inthose addition, charting symptoms Network Child inthe will to SSRIs). helpfulbe with depression as it is inadults (as an augment methyl-tetrahydrofolatethe could also reductase deficiency l-methylfolate forwith (rather with those than folate itself) bipolar disorder, illness present with in vitamin deficiencies D might considered. be combination of vitamins and minerals such as EMPowerplus and stimulant augmentation, augmentation with acomplex behavior despite multiple attempts at stabilization mood worthwhile. but ultimate the result would most likely prove effort the a group community, to inthe setting find may difficult be Such psychotherapeutic an expert practitioner or work in high incidencehigh of outright of vitamin deficiency D as augmentation of fluoxetine was positive. Thus, given the other mixed results, arecent placebo-controlled study for not using punitive highly discipline measures. behavioral therapy and problem solving, and suggestions charting, improved family communication, cognitive- education,illness continued and behavioral mood detailed strongly recommended, ifit particularly emphasized family or group psychotherapeutic would modality be Psychotherapeutic Approaches bipolar disorder is long past due. and compound inchildren with difficult-to-treat A more multifaceted systematic vitaminthis examination of should reducedlithium be or eliminated. such that of dose the preparation this when incombination is used with lithium dyscontrol. However, there are potential adverse reactions bipolar disorder often complicated by extreme behavioral treatmentthe of medication-nonresponsive children with indicated effectiveness the and safety of EMPowerplus in treatment are sequences somewhat out. better spelled for adults with bipolar disorder for whom options the and an optimal outcome. We have found case the to this be rating invaluable measures be will inhelping to achieve Network Child the or some other systematic longitudinal and Charting Mood Treatment Principles patientsall were now receiving treatment as usual. persisted and were enhanced over next the 4years even when had fewer relapses over 2years, these and differences the to treatment as usual. Youngsters receiving care specialty the werewho randomized to 2years of clinic specialty compared outcome of patients with afirst hospitalization for mania positive open data unipolar depressed adults of vitamin D those who were who those notfor selected a vitamin D In might who those have had gene testing, supplementation A very high percentage high A very of children with psychiatric serious If this child persisted in havingthis levels high ofIf oppositional The addition of therapy family-focused or arelated We and many others charting that believe in mood the © 2017Copyright Physicians Postgraduate Press, Inc. Prim Care Companion CNSDisord 2017;19(4):17r02122 53 47,59 Kessing etal

we would addsupplemental vitamin D 52 in patients aged 6–17 years old with 47 Small open clinical trials open clinical Small 60 demonstrated superior the 3 (1,500IU/day in 3 deficiency) deficiency) 3 . 50 54,55 3 Among Among and the and the have have 31 51 56–58 3 In In in .

You are prohibited from making this PDF publicly available. Prim Care Companion CNSDisord 2017;19(4):17r02122 For [email protected]. reprints orpermissions, contact ♦ 9. 8. 7. 6. 5. 4. 3. 2. 1. Funding/support: None. article. this of subject the to related interest of Validus. Pamlabs, Sunovion, and bureau for AstraZeneca, speakers the on been has Post Dr Validus. Tris, and Takeda, Teva, Syneurx, Supernus, Sunovion, Shire, Sage, Roche, Inc, Press Postgraduate Physicians National Institutes of Health, Neurim, PCORI, Pfizer, Medgenics, Lundbeck, KemPharm, Ironshore, Genentech, Forest, Solutions, Epharma Bracket, Press, Psychiatric American Psychiatry, Adolescent and Child of Academy American Alcobra, Akili, for bureau aspeaker’s on served and/or consultant a as acted has and from support research months, Dr Findling 12 past the In interest: of conflicts Potential Published online: 2017. Submitted: REFERENCES child herself or himself. Evidence from gleaned charting of individualfor optimalthe therapeutics response is the of systematicthe treatment data are sparse, guidance so best the bipolarchildhood disorders and related syndromes wherein intervention. at risk and high thus help foster earlier and more effective It isIt illegal to post this copyrighted PDF on any website.

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