In rare cases, the first beginnings can be traced back even to before the tenth year.

Kraepelin, 1921

Adam (a pseudonym), age 9, was hospitalized on a psychiatric ward for young children. (Identifying information has been altered in this report to disguise patient identity.) Before this initial inpatient admission, Adam had lived with his parents and two siblings and had just completed fourth grade. He had received no prescribed or over-the-counter psychotropic medications. For several weeks preceding his hospitalization, Adam had become increasingly distressed over lack of contact with his father, who was working at two jobs. He had also become more irritable and aggressive, fighting frequently with his siblings and peers. After his father canceled an outing planned for the two of them, Adam, threatening suicide, jumped out of a window at his home. Although Adam was uninjured, his parents were alarmed by the recent deterioration in his behavior and brought him to the emergency room, where he was subsequently admitted for inpatient evaluation.

Adam was born after a full-term pregnancy and normal delivery. His mother had smoked up to a pack of cigarettes daily during the pregnancy. Adam reached developmental speech and motor milestones within normal time limits. During the toddler years, Adam’s unusually high activity level and frequent temper tantrums became a concern. In preschool and kindergarten, Adam was noted to have a short attention span and to have difficulty settling down during quiet times and remaining seated. His play was often rough, and he displayed a low tolerance for frustration with his peers. Adam’s social and behavioral problems persisted into elementary school.

Adam was in good general health. There was no history of physical or sexual abuse or head trauma. The results of physical and neurological examinations were unremarkable. The results of blood chemistries, a liver panel, a CBC, tests of thyroid function, a urinalysis, an ECG, and an EEG were normal. No other brain imaging studies were completed. At the time Adam was originally assessed, pertinent family psychiatric history was limited to reports of "anger problems" in Adam’s brother and father. Over time, however, it became clear that Adam’s father, who had not received psychiatric evaluation or treatment, experienced periods of moodiness with volatile temper outbursts, intermittent alcohol binges, and an unstable work history. Of note, his mother developed an initial major depressive episode about 9 months after Adam’s first hospitalization.

When he was first examined, Adam was a somewhat overweight young boy who avoided eye contact but was otherwise cooperative. He appeared moderately depressed. His thought processes were goal-directed, and he reported no auditory hallucinations or racing thoughts. On the Children’s Depression Inventory +(19)—a self-report scale of depressive symptoms for children ages 6–18 that is similar to the Beck Depression Inventory +(20)—Adam endorsed a prominent depressed mood, anhedonia, negative self-esteem, and the feeling of being unloved at the time of admission. His T score was 95 on this self-report scale, on which a score above 69 is considered to be clinically significant for depression. Upon projective testing with the Thematic Apperception Test, his responses emphasized feelings of personal ineffectiveness, vulnerability, and social isolation. Adam’s score on the Children’s Global Assessment Scale (GAS) +(21)—an adaptation of the adult GAS +(22)—was 31. His score on the ADHD Rating Scale +(23), retrospectively completed by a physician on the basis of ward and classroom observations, was 39. In a normative community sample of 9-year-old boys, mean parent and teacher scores on this measure were 13.4 (SD=12.4) and 14.0 (SD=10.4), respectively.

During an initial period of observation, Adam partially responded to the ward’s highly structured behavioral milieu. While his initial suicidal ideation quickly disappeared, he continued to appear sad, withdrawn, and anxious. Adam was diagnosed with a major depressive episode, possibly comorbid with ADHD. Paroxetine, 10 mg/day, was initiated to target his depressive symptoms. Additional interventions included individual therapy and social skills group therapy for Adam, as well as psychoeducation and parent training sessions for Adam’s mother. Adam’s clinical condition improved, and he was discharged after a 2-week inpatient stay. His Children’s Depression Inventory score was 14, his Children’s GAS score was 50, and his ADHD Rating Scale score was 36. Follow-up, to include psychotherapy, ongoing monitoring of antidepressant response, and evaluation of need for additional ADHD pharmacotherapy, was planned.

Adam’s depressive symptoms improved while he was taking paroxetine, 10 mg/day, after his return home, which coincided with the summer months and his return to school in the fall. Despite sustained improvement of his depressive symptoms, Adam continued to experience multiple, impairing symptoms of ADHD at school and at home. Therefore, methylphenidate, 5 mg t.i.d., was added to Adam’s antidepressant regimen to target his inattentiveness, distractibility, and hyperactivity. Before treatment with methylphenidate, Adam’s Children’s GAS score was 55; his ADHD Rating Scale score was 36. One week after he began taking methylphenidate, his ADHD Rating Scale score was 19.

After 8 months of paroxetine and 1.5 months of methylphenidate treatment, Adam’s mood deteriorated in a pattern suggestive of possible manic-like symptoms. His teachers observed that he was more bossy, intrusive, and aggressive with peers. His classroom behavior was more disruptive, and he had become increasingly defiant toward teachers, refusing to accept corrections on assignments.

At home Adam was restless, agitated, and increasingly oppositional. His extreme refusal to accept adult directives at home and at school had a possible grandiose quality, as if "the rules did not apply" to him. His speech was pressured, he began using sexually graphic profanity, and he was caught stealing from his grandmother. Adam also began to defy his bedtime limits, staying up past midnight playing computer games. According to his mother, he was sleeping about 2–3 hours less than usual at night and was not napping during the daytime. Finally, Adam was suspended from an after-school program after he attempted to choke a peer. When his parents attempted to discipline him for this suspension by taking away his television privileges, he shouted that he wanted to kill himself and attempted to stick his arm in the garbage disposal while it was running. After this incident, Adam was readmitted to the child inpatient service.

At his second admission, 8 months after his first hospitalization, Adam appeared in an agitated state, stating, "My motor’s going so fast. I’m about to explode." He described his mood as angry and exhibited labile affect, pressured speech, intrusive behavior, and unfounded suspiciousness toward peers. Once he was ensconced on the ward, his mood was also noted to be expansive, with periods of inappropriate giddiness alternating with extreme irritability and prolonged angry outbursts. Adam was observed to appear physically driven, with a degree of psychomotor hyperactivity that clearly exceeded the activity levels observed during his first hospitalization. There were numerous episodes of physical aggression toward male peers and staff and inappropriate attempts to kiss female peers, resulting in multiple time-outs in open seclusion and one-to-one staffing for safety. In light of his intervening history and clinical presentation in the hospital, Adam was given a presumptive diagnosis of bipolar disorder.

His Children’s Depression Inventory score was 10, his Children’s GAS score was 20, and his ADHD Rating Scale score was 42. Adam’s score on the Young Mania Rating Scale +(24)—retrospectively completed on the basis of detailed multidisciplinary inpatient documentation—was 36. In adults, Young Mania Rating Scale scores greater than 12 suggest hypomania, while scores greater than 20 are usually consistent with mania. While normative data in children are not available for this measure, Fristad et al. +(25) published an open pilot study on its use among 11 prepubertal subjects ages 6–12. In that study, the Young Mania Rating Scale distinguished manic children, whose scores ranged from 14 to 39, from children with ADHD, who received scores of 0–12.

On admission, Adam’s methylphenidate and paroxetine doses were discontinued. Adam’s acute agitation and paranoid ideation were treated with haloperidol, and he began taking lithium. After a 2-week stay, he no longer met criteria for inpatient treatment and was discharged while he was taking 600 mg/day of lithium (serum level=0.8 meq/liter) and 1 mg of haloperidol at bedtime. His Young Mania Rating Scale and Children’s GAS scores were 15 and 50, respectively.

Adam’s mood instability, irritability, and aggression were better while he was taking lithium (serum levels=1.0–1.2 meq/liter) and 1 mg of haloperidol at bedtime for several weeks. His frequent, prolonged temper tantrums and explosive agitation ceased. He was less aggressive toward other children and reported no suicidal ideation. However, about 1 month after Adam’s return home, his mother appeared to develop clinical depression, identifying the death of Adam’s maternal grandfather 6 months earlier, worsening marital conflict, and the stress of Adam’s illness as possible precipitants. She was seen with fatigue, a depressed mood, hypersomnia, complaints of being "unable to cope" accompanied by impaired functioning, and passive suicidal ideation. Adam’s clinical status rapidly deteriorated in the context of maternal impairment, parental discord, and the recent loss of his grandfather. He began to have numerous fistfights with peers, despite continued compliance with medication treatment.

A third hospitalization was precipitated when Adam was expelled from school for making homicidal threats that were accompanied by severe physical aggression toward peers and escalating behavioral dyscontrol at home. Upon rehospitalization, his score on the Young Mania Rating Scale was 31, and his Children’s GAS score was 35. The addition of an anticonvulsant mood stabilizer to lithium was proposed. However, Adam’s parents refused the addition of divalproex sodium and requested that lithium be withdrawn because Adam had experienced a 20-lb weight gain while taking lithium. Carbamazepine was therefore initiated and titrated, on the basis of clinical response, to a serum level of 10 μg/ml, while lithium therapy was gradually withdrawn. Adam responded well to carbamazepine, with marked reductions in irritability and mood lability observed after 2 weeks of treatment. However, he continued to experience multiple, impairing symptoms of distractibility and hyperactivity on the ward and in the classroom. His ADHD Rating Scale score was 35. Because of Adam’s prior history of possible psychostimulant-associated mood destabilization, clonidine therapy was initiated to target residual ADHD symptoms. Adam was discharged from the hospital while taking carbamazepine (serum level=10 μg/liter), 0.05 mg t.i.d. of clonidine, and 1.5 mg/day of haloperidol. His Young Mania Rating Scale score was 11, his Children’s GAS score was 55, and his ADHD Rating Scale score was 25.

Psychoeducational testing revealed that—despite an average cognitive ability (estimated full-scale IQ=96)—Adam’s academic achievement lagged 2–3 years behind in most subjects, and he fulfilled criteria for a developmental reading disorder as well as a disorder of written expression. In addition, his numerous behavioral problems had handicapped his social adaptation. Ameliorating Adam’s experiences of academic and social failure at school thus became one of the principal goals of his outpatient treatment. To achieve this goal, funding was ultimately obtained for Adam to attend a specialized day school for children with severe emotional disturbances and learning disabilities.

Adam’s specialized school provided a safe, controlled environment, a highly structured behavioral program, remedial academic instruction, individual and family therapy, and intensive social skills training. In this therapeutic milieu, Adam was able to make progress both academically and socially; consequently, his self-esteem and conduct improved considerably. Indeed, both Adam and his mother considered placement in this "new school" to be one of the most effective interventions Adam had yet received.

As shown during his first hospitalization, Adam was quite sensitive to the family environment. During his outpatient treatment, his mother was diagnosed with clinical depression and was referred for her own treatment. Initially resistant to psychiatric referral, she agreed when Adam’s sensitivity to her psychological state was emphasized. Improvement in her clinical condition proved beneficial for Adam as well, who responded positively to her greater emotional availability when she was euthymic.

However, Adam also remained a highly vulnerable child who could decompensate quickly without the high level of intervention provided by his therapeutic school environment and his pharmacotherapy—or in response to significant familial and interpersonal stress. Initially, both he and his parents expressed a desire for short-term psychiatric treatment. Working toward a realistic acceptance of the long-term nature of his illness and the necessity for ongoing multimodal interventions proved to be a crucial component of Adam’s treatment.

After his three hospitalizations and over the subsequent year of outpatient treatment, Adam’s mood lability and ADHD symptoms remained improved. Adam did experience several, brief episodes of mild to moderate hypomanic-like activation; however, there were no further hospitalizations. At the time of termination, Adam was taking carbamazepine (serum level=7 μg/liter), 0.05 mg b.i.d. of clonidine and 0.1 mg at bedtime, and 1.0 mg of haloperidol at bedtime. His score on the Children’s GAS was 61, his Young Mania Rating Scale score was 9, and his ADHD Rating Scale score was 22.