There has been increasing recognition that many children with ADHD exhibit depressive and manic-like symptoms that produce substantial impairment across several functional domains. The diagnostic and prognostic implications of these mood symptoms in ADHD children have become a major clinical controversy, with some considering them to be evidence of early onset Bipolar Disorder (BP). Our preliminary work has found that these children are more impaired than those with uncomplicated ADHD, at increased risk for developing depression and BP, have elevated rates of familial mood disorders and respond positively to traditional ADHD treatments but need additional treatments to achieve optimal functioning. The pharmacological management of children with ADHD plus impairments in mood (AIM) is a clinical dilemma as little is known about the safety of stimulants in children with manic symptoms, and it is difficult to justify the use of mood stabilizers or antipsychotics in children without clear manic episodes. Psychosocial interventions hold particular promise for children with AIM as they are well studied, pediatric treatments with little risk of worsening mood symptoms. A psychosocial treatment that targets ADHD and mood symptoms, while conjointly addressing affective symptoms in the parents, can be combined with medications and easily administered to children and families would be an ideal treatment for AIM. We propose to develop an integrative psychosocial treatment that combines aspects of behavior modification programs for ADHD with cognitive-behavioral and psychoeducation techniques for pediatric and adult mood disorders. This novel therapy combined with stimulant medication will be compared to standard ADHD treatment (stimulants) under controlled settings in children with ADHD and impaired mood (AIM). This study will also assess the efficacy and tolerability of stimulants in mood labile youth. The novel therapy holds substantial public health benefit as it will be the one the first to systematically target both internalizing and externalizing symptoms in children with ADHD and represents one of the few multimodal intervention studies for children with possible bipolar spectrum illness. The results are intended to serve as preliminary investigations into the development of multimodal interventions for children with ADHD and BP and the long term outcomes of ADHD youth with early onset mood symptoms.
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