Current concepts in the validity, diagnosis and treatment of paediatric bipolar disorder
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SECTION S P EC I A L International Journal of Neuropsychopharmacology (2003), 6, 293–300. Copyright f 2003 CINP DOI : 10.1017/S1461145703003547 Current concepts in the validity, diagnosis and treatment of paediatric bipolar disorder Joseph Biederman, Eric Mick, Stephen V. Faraone, Thomas Spencer, Timothy E. Wilens and Janet Wozniak Pediatric Psychopharmacology Unit, Massachusetts General Hospital, Boston, MA, USA and Harvard Medical School, Boston, MA, USA Abstract Downloaded from https://academic.oup.com/ijnp/article-abstract/6/3/293/664295 by guest on 28 January 2020 Despite ongoing controversy, the view that paediatric bipolar disorder is rare or non-existent has been increasingly challenged not only by case reports but also by systematic research. This research strongly suggests that paediatric bipolar disorder may not be rare but that it may be diﬃcult to diagnose. Since children with bipolar disorder are likely to become adults with bipolar disorder, the recognition and characterization of childhood-onset bipolar disorder may help identify a meaningful developmental subtype of bipolar disorder worthy of further investigation. As recommended by Robins and Guze [American Journal of Psychiatry (1970), 126, 983–987], a psychiatric disorder may be considered a valid diagnostic entity if it can be shown to have diﬀerentiating features, evidence of familiality, speciﬁc treat- ment responsivity and a unique course. The goal of this article is to review our work and the extant literature within this framework to describe the evidence supporting bipolar disorder in children as a valid clinical diagnosis. Received 28 July 2002 ; Reviewed 29 October 2002 ; Revised 25 March 2003 ; Accepted 30 March 2003 Key words : Adolescents, ADHD, bipolar disorder, children, conduct disorder. Introduction Historical overview Despite continued debate and controversy over the Over the last two decades, the view that bipolar dis- diagnosis of bipolar disorder in children (Biederman, order in children is extremely rare or non-existent has 1998; Klein et al., 1998), exhaustive reviews support been increasingly challenged by many case reports and the existence of the disorder in youth (Faedda et al., series. DeLong and Nieman (1983) described a series of 1995; Geller and Luby, 1997; Weller et al., 1995). Yet, children presenting with severe symptoms highly sug- lingering concerns remain as to its validity. As rec- gestive of bipolar disorder and responsive to lithium ommended by Robins and Guze (1970), a psychiatric carbonate. Carlson (1984) suggested that prepubertal disorder may be considered a valid diagnostic entity if bipolar disorder may be characterized by severe irri- it can be shown to have diﬀerentiating features, evi- tability, absence of episodes and high levels of hyper- dence of familiality, speciﬁc treatment responsivity activity. Similarly, Akiskal et al. (1985) reported on the and a unique course. Considering that the controversy case histories of a large group of adolescent relatives of surrounding this disorder and diagnostic nihilism in- ‘classic ’ adult bipolar patients. They found that de- hibits the study and treatment of these children, ap- spite frank symptoms of depression and bipolar dis- plication of these criteria to this condition is sorely order, and frequent mental health contacts, none of needed. The purpose of this review is to summarize these youth had been diagnosed with an aﬀective our programme of research and the research of others disorder. Weller et al. (1986) then reviewed over 200 within this framework in order to document what is articles published between the years of 1809 ad 1982 known regarding bipolar disorder in children. and identiﬁed 157 cases which would probably be considered manic by modern standards. However, 48 % of those subjects retrospectively diagnosed as Address for correspondence : Dr J. Biederman, Pediatric manic according to DSM-III criteria were not con- Psychopharmacology Unit (ACC 725), Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114-3139, USA. sidered so at the time of referral. Taken together, these Tel.: 617-726-1731 Fax : 617-724-1540 reports suggested that paediatric bipolar disorder may E-mail : email@example.com not be rare, but diﬃcult to diagnose.
294 J. Biederman et al. Diﬀerentiating features provide a valuable touchstone for evaluating the val- idity of the diagnosis made in children, since bipolar Atypical clinical presentation disorder in adolescence has been more readily ac- The atypicality (by adult standards) of the clinical cepted (Ballenger et al., 1982; McGlashan, 1988). Far- picture of childhood bipolar disorder has long been aone et al. (1997b) compared the features of the mania recognized (Davis, 1979; Weinberg and Brumback, in children with the diagnosis, in adolescents with 1976). Notably, the literature consistently shows that child-onset bipolar disorder, and in adolescents with bipolar disorder in children is seldom characterized by adolescent-onset bipolar disorder. With the exception euphoric mood (Carlson, 1983, 1984). Rather, the most of more euphoria among adolescents with adolescent- common mood disturbance in manic children is severe onset bipolar disorder, the frequencies of other symp- irritability, with ‘aﬀective storms ’, or prolonged and toms of mania were strikingly similar between child aggressive temper outbursts (Davis, 1979). The type of and adolescent youth with bipolar disorder. As was Downloaded from https://academic.oup.com/ijnp/article-abstract/6/3/293/664295 by guest on 28 January 2020 irritability observed in manic children is very severe, the case for children, the clinical presentation of bi- persistent, and often violent (Wozniak et al., 1995a). polar disorder among adolescents with childhood- The outbursts often include threatening or attacking onset was rarely biphasic ; it was usually chronic behaviour towards family members, other children, and mixed with a simultaneous onset of depression adults and teachers. In between outbursts, these chil- and mania (Faraone et al., 1997b). These results sug- dren are described as persistently irritable or angry in gested that despite atypicality the proﬁle of manic mood (Carlson, 1983, 1984; Geller and Luby, 1997). features associated with childhood bipolar disorder Thus, it is not surprising that these children frequently may in fact represent a clinically meaningful manic receive the diagnosis of conduct disorder. Aggressive syndrome. symptoms may be the primary reason for the high rate While the adult course of paediatric bipolar dis- of psychiatric hospitalization noted in manic children order awaits data from longitudinal studies, the adult (Wozniak et al., 1995a). literature provides some interesting clues on the sub- In addition to the predominant abnormal mood in ject. A review by McElroy et al. (1992) described paediatric bipolar disorder, its natural course is also ‘ mixed mania’, which aﬀects 20–30 % of adults with atypical compared with the natural course of adult bipolar disorder. Subjects with mixed mania tend to bipolar disorder. The course of paediatric bipolar dis- have a chronic course, absence of discrete episodes, order tends to be chronic and continuous rather than onset of the disorder in childhood and adolescence, a episodic and acute (Carlson, 1983, 1984; Feinstein and high rate of suicide, poor response to treatment, and Wolpert, 1973; McGlashan, 1988). For example, in a re- an early history of neuropsychological deﬁcits highly cent review of the past 10 yr of research on paediatric suggestive of attention deﬁcit hyperactivity disorder bipolar disorder, Geller and Luby (1997) concluded that (ADHD). Thus, McElroy et al. (1992) identiﬁed a manic childhood-onset bipolar disorder is a non-episodic, syndrome in adults that shows the atypical features chronic, rapid-cycling, mixed manic state. Such ﬁnd- of paediatric bipolar disorder. These ﬁndings suggest ings have also been reported by Wozniak et al. (1995a) that paediatric cases with bipolar disorder may de- who found that the overwhelming majority of 43 velop into adults with mixed mania and thereby pro- children from an outpatient psychopharmacology vide further evidence that the atypical manic features clinic who met diagnostic criteria for bipolar disorder of children constitute a valid disorder. on structured diagnostic interview, presented with chronic, and mixed presentation. Carlson et al. (2000) Comorbidity with ADHD reported that early-onset manics were more likely to have comorbid behaviour disorders in childhood and A leading source of diagnostic confusion in childhood to have fewer episodes of remission of a 2-yr period bipolar disorder is its symptomatic overlap with than were adult onset cases of bipolar disorder. Thus, ADHD. Systematic studies of children and adolescents paediatric bipolar disorder appears to present with an show that rates of ADHD range from 60 to 90 % in atypical picture characterized by predominantly irri- paediatric patients with bipolar disorder (Borchardt table mood, mania mixed with symptoms of major and Bernstein, 1995; Geller et al., 1995; West et al., depression, and chronic as opposed to euphoric, bi- 1995; Wozniak et al., 1995a). Although the rates of phasic, and episodic course. ADHD in samples of youth with bipolar disorder is Although the atypical features noted in children universally high, the age at onset modiﬁes the risk for with manic-like symptoms raises the possibility of comorbid ADHD. For example, while Wozniak (1995a) misdiagnosis, adolescents with bipolar disorder may found that 90 % of children with bipolar disorder also
Validity of bipolar disorder in children 295 had ADHD, West et al. (1995), reported that only 57 % The potential for diﬀerent rates of comorbidity of adolescents with bipolar disorder were comorbid with bipolar disorder in the combined-subtype, in- with ADHD. Examining further developmental aspects attentive-subtype and hyperactive impulsive-subtype of paediatric bipolar disorder, Faraone et al. (1997 b) of ADHD requires further research. Faraone et al. found that adolescents with childhood-onset bipolar (1998a) studied 301 ADHD children and adolescents disorder had the same rates of comorbid ADHD as consecutively referred to a paediatric psychopharma- manic children (90 %) and that both these groups cology clinic. Among these, 185 (61 %) were the com- had higher rates of ADHD than adolescents with bined type, 89 (30 %) the inattentive type and 27 (9 %) adolescent-onset bipolar disorder (60 %). Furthermore, the hyperactive/impulsive type. Bipolar disorder was Sachs et al. (2000) reported that, among adults with highest among combined-type youth (26.5 %) but was bipolar disorder, a history of comorbid ADHD was also elevated among hyperactive-impulsive (14.3 %) only evident in those subjects with onset of bipolar and inattentive (8.7 %) youth. Downloaded from https://academic.oup.com/ijnp/article-abstract/6/3/293/664295 by guest on 28 January 2020 disorder before age 19 yr. The mean onset of bipolar disorder in those with a history of childhood ADHD Comorbidity with conduct disorder (CD) was 12.1 yr (Sachs et al., 2000). Similarly, Chang et al. (2000) studied the oﬀspring of patients with bipolar Like ADHD, CD is also strongly associated with paedi- disorder and found that 80 % of manic children had atric bipolar disorder. This has been seen separately in comorbid ADHD and that the onset of bipolar dis- studies of children with CD, ADHD and bipolar dis- order in adults with bipolar disorder and a history of order. Wozniak et al. (1995a) reported that pre- ADHD was 11.3 yr. These ﬁndings suggested that age adolescent children satisfying structured interview of onset of bipolar disorder, rather than chronological criteria for bipolar disorder often had comorbid CD. age at presentation, may be the critical developmental Kovacs and Pollock (1995) reported a 69 % rate of CD variable that identiﬁes a highly virulent form of the in a referred sample of manic youth and found that disorder that is heavily comorbid with ADHD. the presence of comorbid CD heralded a more com- One problem facing studies of ADHD and bipolar plicated course of bipolar disorder. Similar ﬁndings disorder is that these disorders share diagnostic cri- were reported by Kutcher et al. (1989) who found that teria. Of seven DSM-III-R criteria for a manic episode, 42 % of hospitalized youths with bipolar disorder three are shared with the DSM-III-R criteria for had comorbid CD. The Zurich longitudinal study, ADHD : distractibility, motoric hyperactivity, and talk- found that hypomanic cases had more disciplinary ativeness. To avoid counting symptoms twice toward diﬃculties at school and more thefts during their the diagnosis of both ADHD and bipolar disorder, two juvenile years than other children (Wicki and Angst, diﬀerent techniques of correcting for overlapping di- 1991). These reports are consistent with the well- agnostic criteria have been used to evaluate the associ- documented comorbidity between CD and major de- ation between ADHD and paediatric bipolar disorder pression (Angold and Costello, 1993) considering that (Biederman et al., 1996). juvenile depression often presages bipolar disorder In the subtraction method, overlapping symptoms (Geller et al., 1994; Strober and Carlson, 1982). are simply not counted when making the diagnosis. In Biederman et al. (1997, 1999) investigated the over- the proportion method, overlapping symptoms are lap between bipolar disorder and CD in a consecutive not counted but the diagnostic threshold is lowered to sample of referred youth and in a sample of ADHD require that the same proportion of symptoms from subjects to clarify its prevalence and correlates. They the reduced set is as that required for the original di- found a striking similarity in the features of bipolar agnosis (Milberger et al., 1995). Using these methods, disorder regardless of comorbid CD. Additionally, the Biederman et al. (1996) showed that 48 % of children age at onset of bipolar disorder was similar in sub- with bipolar disorder continued to meet criteria by jects with or without comorbid CD. In both groups, the subtraction method and 69 % by the proportion mania presented with a predominantly irritable mood, method. A total of 89 % of children with bipolar dis- a chronic course, and was mixed with symptoms of order maintained a full diagnosis of ADHD using the major depression. Only two manic symptoms diﬀered subtraction method and 93 % maintained the ADHD between these groups : ‘physical restlessness ’ and diagnosis by the proportion method. Taken together ‘poor judgement ’ were more common in the bipolar these results suggest that the comorbidity between disorder with CD group compared to the bipolar ADHD and paediatric bipolar disorder is not a meth- disorder-only group. Similarly, there were few diﬀer- odological artifact due to diagnostic criteria shared by ences in the frequency of CD symptoms between CD the two disorders. youth with and without comorbid bipolar disorder.
296 J. Biederman et al. Although children with CD and bipolar disorder had a data from a longitudinal sample of boys with and higher rate of ‘vandalizing ’ compared to CD-only sub- without ADHD, Wozniak et al. (1999) identiﬁed paedi- jects, this diﬀerence was not statistically signiﬁcant. atric bipolar disorder as an important antecedent Both the comorbid and non-comorbid subjects with for, rather than consequence of, traumatic life events. mania had high rates of major depression, anxiety This temporal relationship between bipolar disorder disorders, oppositional disorder, and psychosis than and traumatic events could have important clinical CD and ADHD children (Biederman et al., 1997, 1999). and therapeutic implications. When traumatized chil- In addition bipolar disorder comorbid with CD was dren present with severe irritability and mood lability, associated with poorer functioning and an increased there may be a tendency by clinicians to attribute these risk for psychiatric hospitalization (Biederman et al., symptoms to having experienced a trauma. Longi- 1997). Subjects with both CD and bipolar disorder also tudinal research, however, suggests the opposite; had a higher familial and personal risk for mood dis- bipolar disorder may be an antecedent risk factor for Downloaded from https://academic.oup.com/ijnp/article-abstract/6/3/293/664295 by guest on 28 January 2020 orders than other CD subjects who had a higher per- later trauma and not represent a reaction to the trauma sonal risk for antisocial personality disorder (Faraone (Wozniak et al., 1999). et al., 1998b). Taken together, these studies suggest that subjects Familial aggregation who receive diagnoses of both CD and bipolar dis- order may, in fact, have both disorders. While the Although there are no twin or adoption studies of resolution of this important issue awaits further re- paediatric bipolar disorder, family studies strongly search, the mere diagnosis of bipolar disorder in some suggest that the paediatric onset form of the disorder CD children oﬀers important therapeutic possibilities has a strong familial component (Faraone et al., 1997a ; since delinquency and bipolar disorder require very Strober, 1992; Strober et al., 1988 ; Todd et al., 1996; diﬀerent treatment strategies. Wozniak et al., 1995b). Strober (1992), Strober et al. (1988) and Todd et al. (1993) proposed that paediatric bipolar disorder might be a distinct subtype of bipolar Paediatric bipolar disorder and trauma disorder with a high familial loading. In examining the Although it has been long suspected that bipolar dis- comorbidity between bipolar disorder in children and order in children may be the result of trauma and ADHD or CD, we have reported on the familiality associations between trauma and bipolar disorder of bipolar disorder in families ascertained via child have been reported in adults, there has been relatively probands (Faraone et al., 1997a, 2001; Wozniak et al., limited systematic research of this issue. Kessler 1995b). et al. (1995) found elevated lifetime rates of bipolar We ﬁrst examined the familiality of bipolar disorder disorder among adult and adolescent subjects with in children in a pilot sample of 16 families ascertained post-traumatic stress disorder (PTSD). Helzer et al. via a child proband with the disorder (Wozniak et al., (1987) reported a strong association between manic- 1995b). We compared the relatives of manic children depressive illness and PTSD in adult subjects but did to the relatives of ADHD children without bipolar not determine if bipolar disorder was primary or sec- disorder and to normal controls. Among the 46 ﬁrst- ondary to the trauma. This report further suggested degree relatives of 16 children with bipolar disorder, that behavioural problems including ‘stealing, lying, 13 % (n=6) met criteria for bipolar disorder with as- truancy, vandalism, running away, ﬁghting, misbe- sociated impairment. This diﬀered signiﬁcantly from haviour at school, early sexual experience, substance both the ADHD (2 %; n=7) and normal control (3 %; abuse, school expulsion or suspension, academic n=7) groups. The relatives of ADHD and control underachievement, and delinquency ’ prior to age probands did not diﬀer in their risk for bipolar dis- 15 yr predicted later PTSD (Helzer et al., 1987). Not order. Almost identical ﬁndings were obtained in two surprisingly, the authors concluded that ‘this associ- independently deﬁned family studies of ADHD pro- ation may mean that persons with such behaviour in bands with and without comorbid bipolar disorder childhood had a greater likelihood of experiencing (Faraone et al., 1998b, 2001). In a sample of boys with trauma later on’. ADHD and their relatives, we found an increased Since juvenile bipolar disorder is commonly associ- family risk of bipolar disorder in children with bipolar ated with extreme violence and severe behavioural disorder (16 %) compared to relatives of non-manic dysregulation (Wozniak et al., 1995a) as well as hyper- children (3 %). Likewise, among families ascertained sexuality, bipolar disorder in children could either be a via girls with ADHD the rate of bipolar disorder reaction to, or a risk factor for, trauma exposure. Using in relatives of ADHD girls with comorbid bipolar
Validity of bipolar disorder in children 297 disorder was signiﬁcantly greater (13 %) than either follow up, only 29 % (the 45 % of the recovered 65 % ADHD girls without bipolar disorder (5 %) or in the that did not relapse) of the original sample would be relatives of normal control girls (3 %) (Faraone et al., considered in remission, overall. In our study, the 2001). deﬁnition of remission that most closely replicates From these three studies, we estimate that the rate what Geller et al. (2002) studied was syndromatic of bipolar disorder in relatives of manic children was remission that we estimated to be 27 % at 2 yr. 2.6–5.3 times higher than in non-manic children. Thus, While the literature examining the long-term follow- the evidence from these samples clearly indicates that up of children with bipolar disorder is scant it docu- the disorder may be highly familial. ments that the disorder is not transient. Even the most optimistic deﬁnition of remission (syndromatic re- mission), was attained by only 30 % of subjects over a Longitudinal course 2-yr period. That less than 20 % of subjects attained Downloaded from https://academic.oup.com/ijnp/article-abstract/6/3/293/664295 by guest on 28 January 2020 Recently, Geller et al. (2002) reported on the 2-yr out- functional remission or euthymia over the entire time- come of a longitudinal sample of children with paedi- period evaluated provides further evidence that paedi- atric bipolar disorder. This study found that by the atric bipolar disorder is a chronic mood disorder with last follow-up period 65 % of subjects recovered from a poor prognosis. bipolar disorder but that 55 % relapsed after recovery. However, since this study focused exclusively on full Treatment response syndromatic persistence of manic symptomatology, it did not address the possibility of continued aﬀective In a series of controlled clinical trials Campbell and instability in the form of sub-syndromal symptoms of colleagues (Campbell et al., 1984, 1995; Cueva et al., the disorder and its associated impairments. 1996) documented the eﬃcacy of mood stabilizers We recently estimated the course of bipolar dis- (lithium carbonate and carbamazepine) in the treat- order in children with ADHD over a period covering ment of aggressive CD children. However, these psy- 10 yr ( J. Biederman et al., unpublished observations) chiatrically hospitalized CD youth were treated for with diﬀerent forms of persistence. As recently pro- severe, uncontrollable and disorganized aggression posed by Keck et al. (1998) the distinction between and not necessarily for delinquency. Thus, it is poss- diﬀerent types of remission may clarify components of ible that the therapeutic beneﬁts observed in these complex recovery processes. These investigators sug- children with anti-manic treatments could have been gested three levels of remission for psychiatric dis- due to the anti-manic eﬀects in treating aggressive orders : syndromatic, symptomatic and functional. manic children satisfying criteria for CD. Syndromatic remission refers to the loss of full diag- Biederman et al. (1998) systematically reviewed the nostic status, symptomatic remission refers to the loss of clinical records of all paediatrically referred patients partial diagnostic status ; functional remission refers to who, at initial intake satisﬁed diagnostic criteria for the loss of partial diagnostic status plus functional re- bipolar disorder based on a structured diagnostic in- covery (full recovery). For bipolar disorder, another terview with the mother. Mood stabilizers were fre- critical dimension in assessing patterns of remission is quently used in these children and their use was the persistence of depressive symptomatology since associated with signiﬁcant improvement of manic-like some subjects may remit from mania but may continue symptoms that their psychiatrists had recorded in the to manifest depression. Thus, Euthymia was deﬁned by medical record. In contrast, antidepressants, typical failing to meet criteria for manic episode or for major antipsychotics, and stimulants were not associated depressive episode at follow-up. with improvement of manic-like symptoms. For both We found that the course of bipolar disorder was lithium carbonate and carbamazepine higher and chronic, protracted, and dysfunctional. Although 50 % more therapeutic doses predicted greater decreases in of bipolar youth remitted from the full syndrome of the manic-like symptoms recorded by the treating bipolar disorder at follow up (i.e. they no longer met clinician in the medical record. full diagnostic criteria), 80 % failed to attain functional Although treatment with mood stabilizers was as- remission or euthymia over a course of 10 yr. Our re- sociated with a statistically signiﬁcant decrease in sults were in line with those of Geller et al. (2002) who manic-like symptoms, this improvement was slow to reported that 65 % of a sample of 89 subjects with develop and was associated with frequent relapses. prepubertal onset bipolar disorder had recovered by Although somewhat discouraging, these ﬁndings the 2-yr follow-up assessment, but that 55 % reported a are consistent with outcome data from naturalistic relapse during the same interval. Thus, at the 2-yr follow-up studies of bipolar children and adults
298 J. Biederman et al. (Strober et al., 1990, 1995). For example, the survival once issues surrounding the validity of bipolar dis- analysis from Biederman et al. (1998) indicated that order in children are adequately addressed. 65 % of the children would improve if treated with lithium carbonate for 2 yr. This ﬁnding is remarkably Summary consistent with results from DeLong and Aldershof (1987) who reported a 66 % response rate for manic The emerging literature indicates that bipolar disorder children treated with lithium carbonate over a 10- to can be identiﬁed in a substantial number of referred 70-month treatment period and with ﬁndings re- children using systematic assessment methodology. ported by Strober et al. (1995) showing that multiple Thus, this disorder may not be as rare as previously relapses were most often seen in subjects with mixed considered. Children with bipolar disorder frequently mania. demonstrate an atypical picture by adult standards More optimistic ﬁndings have resulted from in- with a chronic course, severely irritable mood, and a Downloaded from https://academic.oup.com/ijnp/article-abstract/6/3/293/664295 by guest on 28 January 2020 vestigations of atypical neuroleptics in the treatment mixed picture with depressive and manic symptoms of juveniles with bipolar disorder. In a retrospective co-occurring, and increased risk to relatives. Initial chart review study of 28 youths with bipolar disorder, clinical evidence suggests that atypical neuroleptics 82 % of subjects showed improvement in both manic may play a unique therapeutic role in the management and aggressive symptoms with risperidone treatment of such youth. The high level of comorbidity with (Frazier et al., 1999b). In contrast to the duration of other disorders is common, further requiring the cau- treatment required for improvement with mood stabil- tious use of a combined pharmacotherapy approach. izers, the average time to optimal response was 1.9¡ More research is needed to build a scientiﬁc foun- 1.0 months of therapy. Moreover, no serious adverse dation for the notion that paediatric bipolar disorder eﬀects were observed. Similarly encouraging results is a valid developmental subtype of bipolar disorder. were reported by Frazier et al. (1999a) in an open trial With this foundation and continued pilot research of of olanzapine monotherapy. They found that treat- promising psychopharmacological interventions, the ment with olanzapine was associated with signiﬁcant ﬁeld will be able to ethically conduct large-scale, ran- improvements in both the Children’s Depression In- domized clinical trials and, only then, will proven ventory and the Young Mania Rating Scale in 23 manic treatment options emerge. children after 8 wk of monotherapy on doses ranging from 2.5 to 20 mg/d. Similarly, Findling et al. (2000) recently reported References that risperidone was eﬀective in treating aggression in Akiskal HS, Downs J, Jordan P (1985). Aﬀective disorders children with CD. 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