Skip to main content
SpringerLink
Log in

Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder

  • Original Contribution
  • Published:
European Child & Adolescent Psychiatry Aims and scope Submit manuscript

Abstract

Greater understanding of cognitive function in children and adolescents with bipolar disorder (BD) is of critical importance to improve our ability to design targeted treatments to help with real-world impairment, including academic performance. We sought to evaluate cognitive performance among children with either BD type I, II, or “not otherwise specified” (NOS) participating in multi-site Course and Outcome of Bipolar Youth study compared to typically developing controls (TDC) without psychopathology. In particular, we sought to test the hypothesis that BD-I and BD-II youths with full threshold episodes of mania or hypomania would have cognitive deficits, including in reversal learning, vs. those BD-NOS participants with sub-threshold episodes and TDCs. N = 175 participants (BD-I = 81, BD-II = 11, BD-NOS = 28, TDC = 55) completed Cambridge Neuropsychological Automated Testing Battery (CANTAB) tasks. A priori analyses of the simple reversal stage of the CANTAB intra-/extra-dimensional shift task showed that aggregated BD-I/II participants required significantly more trials to complete the task than either BD-NOS participants with sub-syndromal manic/hypomanic symptoms or than TDCs. BD participants across sub-types had impairments in sustained attention and information processing for emotionally valenced words. Our results align with prior findings showing that BD-I/II youths with distinct episodes have specific alterations in reversal learning. More broadly, our study suggests that further work is necessary to see the interaction between neurocognitive performance and longitudinal illness course. Additional work is required to identify the neural underpinnings of these differences as targets for potential novel treatments, such as cognitive remediation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Pavuluri MN, O’Connor MM, Harral EM, Moss M, Sweeney JA (2006) Impact of neurocognitive function on academic difficulties in pediatric bipolar disorder: a clinical translation. Biol Psychiatry 60:951–956

    Article  PubMed  Google Scholar 

  2. Pollack LA, Stewart SL, Thompson TD (2007) Trends in childhood cancer mortality-United States, 1990–2004. MMWR Morb Mortal Wkly Rep 56:1257–1261

    Google Scholar 

  3. Blader JC, Carlson GA (2007) Increased rates of bipolar disorder diagnoses among U.S. child, adolescent, and adult inpatients, 1996–2004. Biol Psychiatry 62:107–114

    Article  PubMed  PubMed Central  Google Scholar 

  4. Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M (2007) National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry 64:1032–1039

    Article  PubMed  Google Scholar 

  5. Holtmann M, Duketis E, Poustka L, Zepf FD, Poustka F, Bolte S (2010) Bipolar disorder in children and adolescents in Germany: national trends in the rates of inpatients, 2000–2007. Bipolar Disord 12:155–163

    Article  PubMed  Google Scholar 

  6. Passarotti AM, Sweeney JA, Pavuluri MN (2010) Emotion processing influences working memory circuits in pediatric bipolar disorder and attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 49:1064–1080

    Article  PubMed  PubMed Central  Google Scholar 

  7. Pavuluri MN, Passarotti AM, Mohammed T, Carbray JA, Sweeney JA (2010) Enhanced working and verbal memory after lamotrigine treatment in pediatric bipolar disorder. Bipolar Disord 12:213–220

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJ, Leibenluft E (2008) Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Dev Psychopathol 20:529–546

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pavuluri MN, Passarotti AM, Harral EM, Sweeney JA (2009) An fMRI study of the neural correlates of incidental versus directed emotion processing in pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry 48:308–319

    Article  PubMed  PubMed Central  Google Scholar 

  10. Brotman MA, Rich BA, Guyer AE, Lunsford JR, Horsey SE, Reising MM, Thomas LA, Fromm SJ, Towbin K, Pine DS, Leibenluft E (2010) Amygdala activation during emotion processing of neutral faces in children with severe mood dysregulation versus ADHD or bipolar disorder. Am J Psychiatry 167:61–69

    Article  PubMed  PubMed Central  Google Scholar 

  11. Dickstein DP, Treland JE, Snow J, McClure EB, Mehta MS, Towbin KE, Pine DS, Leibenluft E (2004) Neuropsychological performance in pediatric bipolar disorder. Biol Psychiatry 55:32–39

    Article  PubMed  Google Scholar 

  12. Gorrindo T, Blair RJ, Budhani S, Dickstein DP, Pine DS, Leibenluft E (2005) Deficits on a probabilistic response-reversal task in patients with pediatric bipolar disorder. Am J Psychiatry 162:1975–1977

    Article  PubMed  Google Scholar 

  13. Dickstein DP, Nelson EE, McClure EB, Grimley ME, Knopf L, Brotman MA, Rich BA, Pine DS, Leibenluft E (2007) Cognitive flexibility in phenotypes of pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry 46:341–355

    Article  PubMed  Google Scholar 

  14. Dickstein DP, Finger EC, Brotman MA, Rich BA, Pine DS, Blair JR, Leibenluft E (2010) Impaired probabilistic reversal learning in youths with mood and anxiety disorders. Psychol Med 40:1089–1100

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Dickstein DP, Finger EC, Skup M, Pine DS, Blair JR, Leibenluft E (2010) Altered neural function in pediatric bipolar disorder during reversal learning. Bipolar Disord 12:707–719

    Article  PubMed  PubMed Central  Google Scholar 

  16. Adleman NE, Kayser R, Dickstein D, Blair RJ, Pine D, Leibenluft E (2011) Neural correlates of reversal learning in severe mood dysregulation and pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry 50:1173–1185

    Article  PubMed  PubMed Central  Google Scholar 

  17. Cools R, Clark L, Owen AM, Robbins TW (2002) Defining the neural mechanisms of probabilistic reversal learning using event-related functional magnetic resonance imaging. J Neurosci 22:4563–4567

    CAS  PubMed  Google Scholar 

  18. Clark L, Cools R, Robbins TW (2004) The neuropsychology of ventral prefrontal cortex: decision-making and reversal learning. Brain Cogn 55:41–53

    Article  CAS  PubMed  Google Scholar 

  19. Blair RJ, Cipolotti L (2000) Impaired social response reversal. A case of ‘acquired sociopathy’. Brain 123(Pt 6):1122–1141

    Article  PubMed  Google Scholar 

  20. Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003) Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160:430–437

    Article  PubMed  Google Scholar 

  21. Blair RJ (2004) The roles of orbital frontal cortex in the modulation of antisocial behavior. Brain Cogn 55:198–208

    Article  CAS  PubMed  Google Scholar 

  22. Rich BA, Schmajuk M, Perez-Edgar KE, Fox NA, Pine DS, Leibenluft E (2007) Different psychophysiological and behavioral responses elicited by frustration in pediatric bipolar disorder and severe mood dysregulation. Am J Psychiatry 164:309–317

    Article  PubMed  Google Scholar 

  23. Blair RJ (2010) Psychopathy, frustration, and reactive aggression: the role of ventromedial prefrontal cortex. Br J Psychol 101:383–399

    Article  CAS  PubMed  Google Scholar 

  24. Horn K, Roessner V, Holtmann M (2011) Neurocognitive performance in children and adolescents with bipolar disorder: a review. Eur Child Adolesc Psychiatry 20:433–450

    Article  PubMed  Google Scholar 

  25. Findling RL, Youngstrom EA, McNamara NK, Stansbrey RJ, Demeter CA, Bedoya D, Kahana SY, Calabrese JR (2005) Early symptoms of mania and the role of parental risk. Bipolar Disord 7:623–634

    Article  PubMed  Google Scholar 

  26. Van Meter A, Youngstrom EA, Youngstrom JK, Feeny NC, Findling RL (2011) Examining the validity of cyclothymic disorder in a youth sample. J Affect Disord 132:55–63

    Article  PubMed  PubMed Central  Google Scholar 

  27. Prisciandaro JJ, Roberts JE (2011) Evidence for the continuous latent structure of mania in the Epidemiologic Catchment Area from multiple latent structure and construct validation methodologies. Psychol Med 41:575–588

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Van Meter AR, Moreira AL, Youngstrom EA (2011) Meta-analysis of epidemiologic studies of pediatric bipolar disorder. J Clin Psychiatry 72(9):1250–1256

    Article  PubMed  Google Scholar 

  29. Axelson D, Birmaher B, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J, Iyengar S, Bridge J, Keller M (2006) Phenomenology of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry 63:1139–1148

    Article  PubMed  Google Scholar 

  30. Birmaher B, Axelson D, Goldstein B, Strober M, Gill MK, Hunt J, Houck P, Ha W, Iyengar S, Kim E, Yen S, Hower H, Esposito-Smythers C, Goldstein T, Ryan N, Keller M (2009) Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course And Outcome Of Bipolar Youth (COBY) study. Am J Psychiatry 166:795–804

    Article  PubMed  PubMed Central  Google Scholar 

  31. Axelson DA, Birmaher B, Strober MA, Goldstein BI, Ha W, Gill MK, Goldstein TR, Yen S, Hower H, Hunt JI, Liao F, Iyengar S, Dickstein D, Kim E, Ryan ND, Frankel E, Keller MB (2011) Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified. J Am Acad Child Adolesc Psychiatry 50:1001–1016

    Article  PubMed  PubMed Central  Google Scholar 

  32. Dickstein DP, Garvey M, Pradella AG, Greenstein DK, Sharp WS, Castellanos FX, Pine DS, Leibenluft E (2005) Neurologic examination abnormalities in children with bipolar disorder or attention-deficit/hyperactivity disorder. Biol Psychiatry 58:517–524

    Article  PubMed  Google Scholar 

  33. Glahn DC, Bearden CE, Caetano S, Fonseca M, Najt P, Hunter K, Pliszka SR, Olvera RL, Soares JC (2005) Declarative memory impairment in pediatric bipolar disorder. Bipolar Disord 7:546–554

    Article  PubMed  Google Scholar 

  34. Birmaher B, Axelson D, Strober M, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J, Iyengar S, Keller M (2006) Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry 63:175–183

    Article  PubMed  PubMed Central  Google Scholar 

  35. Goldstein TR, Birmaher B, Axelson D, Goldstein BI, Gill MK, Esposito-Smythers C, Ryan ND, Strober MA, Hunt J, Keller M (2009) Psychosocial functioning among bipolar youth. J Affect Disord 114:174–183

    Article  PubMed  PubMed Central  Google Scholar 

  36. Sala R, Axelson DA, Castro-Fornieles J, Goldstein TR, Ha W, Liao F, Gill MK, Iyengar S, Strober MA, Goldstein BI, Yen S, Hower H, Hunt J, Ryan ND, Dickstein D, Keller MB, Birmaher B (2010) Comorbid anxiety in children and adolescents with bipolar spectrum disorders: prevalence and clinical correlates. J Clin Psychiatry 71:1344–1350

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hunt JI, Case BG, Birmaher B, Stout RL, Dickstein DP, Yen S, Goldstein TR, Goldstein BI, Axelson DA, Hower H, Strober M, Ryan N, Swenson L, Topor DR, Gill MK, Weinstock LM, Keller MB (2013) Irritability and elation in a large bipolar youth sample: relative symptom severity and clinical outcomes over 4 years. J Clin Psychiatry 74:e110–e117

    Article  PubMed  PubMed Central  Google Scholar 

  38. Axelson D, Birmaher BJ, Brent D, Wassick S, Hoover C, Bridge J, Ryan N (2003) A preliminary study of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children mania rating scale for children and adolescents. J Child Adolesc Psychopharmacol 13:463–470

    Article  PubMed  Google Scholar 

  39. Chambers WJ, Puig-Antich J, Hirsch M, Paez P, Ambrosini PJ, Tabrizi MA, Davies M (1985) The assessment of affective disorders in children and adolescents by semistructured interview. Test-retest reliability of the schedule for affective disorders and schizophrenia for school-age children, present episode version. Arch Gen Psychiatry 42:696–702

    Article  CAS  PubMed  Google Scholar 

  40. Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D, Ryan N (1997) Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988

    Article  CAS  PubMed  Google Scholar 

  41. Keller MB, Lavori PW, Friedman B, Nielsen E, Endicott J, McDonald-Scott P, Andreasen NC (1987) The longitudinal interval follow-up evaluation. A comprehensive method for assessing outcome in prospective longitudinal studies. Arch Gen Psychiatry 44:540–548

    Article  CAS  PubMed  Google Scholar 

  42. Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold LE, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM (2010) Characteristics of children with elevated symptoms of mania: the Longitudinal Assessment of Manic Symptoms (LAMS) study. J Clin Psychiatry 71:1664–1672

    Article  PubMed  PubMed Central  Google Scholar 

  43. Youngstrom EA, Birmaher B, Findling RL (2008) Pediatric bipolar disorder: validity, phenomenology, and recommendations for diagnosis. Bipolar Disord 10:194–214

    Article  PubMed  PubMed Central  Google Scholar 

  44. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Association, Arlington

    Google Scholar 

  45. Clark L, Iversen SD, Goodwin GM (2001) A neuropsychological investigation of prefrontal cortex involvement in acute mania. Am J Psychiatry 158:1605–1611

    Article  CAS  PubMed  Google Scholar 

  46. Clark L, Iversen SD, Goodwin GM (2002) Sustained attention deficit in bipolar disorder. Br J Psychiatry 180:313–319

    Article  PubMed  Google Scholar 

  47. Roiser JP, Cannon DM, Gandhi SK, Taylor TJ, Erickson K, Wood S, Klaver JM, Clark L, Zarate CA Jr, Sahakian BJ, Drevets WC (2009) Hot and cold cognition in unmedicated depressed subjects with bipolar disorder. Bipolar Disord 11:178–189

    Article  PubMed  PubMed Central  Google Scholar 

  48. Rubinsztein JS, Michael A, Paykel ES, Sahakian BJ (2000) Cognitive impairment in remission in bipolar affective disorder. Psychol Med 30:1025–1036

    Article  CAS  PubMed  Google Scholar 

  49. Maalouf FT, Klein C, Clark L, Sahakian BJ, Labarbara EJ, Versace A, Hassel S, Almeida JR, Phillips ML (2010) Impaired sustained attention and executive dysfunction: bipolar disorder versus depression-specific markers of affective disorders. Neuropsychologia 48:1862–1868

    Article  PubMed  PubMed Central  Google Scholar 

  50. Arnold LE, Mount K, Frazier T, Demeter C, Youngstrom EA, Fristad MA, Birmaher B, Horwitz S, Findling RL, Kowatch R, Axelson D (2012) Pediatric bipolar disorder and ADHD: family history comparison in the LAMS clinical sample. J Affect Disord 141:382–389

    Article  PubMed  PubMed Central  Google Scholar 

  51. Passarotti AM, Sweeney JA, Pavuluri MN (2010) Neural correlates of response inhibition in pediatric bipolar disorder and attention deficit hyperactivity disorder. Psychiatry Res 181:36–43

    Article  PubMed  PubMed Central  Google Scholar 

  52. Lopez-Larson M, Michael ES, Terry JE, Breeze JL, Hodge SM, Tang L, Kennedy DN, Moore CM, Makris N, Caviness VS, Frazier JA (2009) Subcortical differences among youths with attention-deficit/hyperactivity disorder compared to those with bipolar disorder with and without attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 19:31–39

    Article  PubMed  PubMed Central  Google Scholar 

  53. Brotman MA, Rich BA, Guyer AE, Lunsford JR, Horsey SE, Reising MM, Thomas LA, Fromm SJ, Towbin K, Pine DS, Leibenluft E (2009) amygdala activation during emotion processing of neutral faces in children with severe mood dysregulation versus ADHD or bipolar disorder. Am J Psychiatry 167:61–69

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

We gratefully thank all participants and their families for being part of this study and the National Institutes of Mental Health (NIMH) for supporting this work—including the Course and Outcome of Bipolar Youth (COBY; R01MH059929), Longitudinal Assessment of Manic Symptoms (LAMS; (R01MH073953, R01MH073801, R01MH073967, R01MH073816), and Dr. Dickstein’s Pediatric Mood, Imaging, and NeuroDevelopment (PediMIND) Program studies (K22MH074945).

Author information

Authors and Affiliations

  1. Department of Psychiatry and Human Behavior, Division of Child-Family Psychiatry, Bradley Hospital, Alpert Medical School of Brown University, East Providence, RI, USA

    Daniel P. Dickstein, Alexandra B. Weissman & Jeffrey I. Hunt

  2. Department of Psychiatry, Nationwide Children’s Hospital, Columbus, OH, USA

    David Axelson & Robert A. Kowatch

  3. Department of Psychiatry and Human Behavior/Butler Hospital, Alpert Medical School of Brown University, Providence, RI, USA

    Shirley Yen & Heather Hower

  4. Department of Child Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto Medical Center, Toronto, ON, Canada

    Benjamin I. Goldstein

  5. Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Tina R. Goldstein, Fangzi Liao, Mary Kay Gill, Rasim S. Diler, Neal D. Ryan & Boris Birmaher

  6. Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA

    Michael Strober

  7. Department of Psychiatry, Center for Autism, Cleveland Clinic, Cleveland, OH, USA

    Thomas W. Frazier

  8. Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Eric A. Youngstrom

  9. Department of Psychiatry, Division of Child and Adolescent Psychiatry, Ohio State University, Columbus, OH, USA

    Mary A. Fristad & L. Eugene Arnold

  10. Department of Psychiatry, Johns Hopkins University, Baltimore, MD, USA

    Robert L. Findling

  11. Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York City, NY, USA

    Sarah M. Horwitz

  12. Butler Hospital, Providence, RI, USA

    Martin B. Keller

  13. PediMIND Program, Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI, 02915, USA

    Daniel P. Dickstein

Authors
  1. Daniel P. Dickstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David Axelson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alexandra B. Weissman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shirley Yen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jeffrey I. Hunt
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Benjamin I. Goldstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Tina R. Goldstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Fangzi Liao
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Mary Kay Gill
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Heather Hower
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Thomas W. Frazier
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Rasim S. Diler
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Eric A. Youngstrom
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Mary A. Fristad
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. L. Eugene Arnold
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Robert L. Findling
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Sarah M. Horwitz
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Robert A. Kowatch
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Neal D. Ryan
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Michael Strober
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. Boris Birmaher
    View author publications

    You can also search for this author in PubMed Google Scholar

  22. Martin B. Keller
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel P. Dickstein.

Ethics declarations

Conflict of interest

Drs. Dickstein, Axelson, Diler, T. Goldstein, Ryan, Liao, Yen, Horwitz, and Kowatch, as well as Ms. Mary Kay Gill, Ms. Heather Hower, and Ms. Alexandra Weissman report no biomedical financial interests or potential conflicts of interest. Dr. Birmaher has received royalties from Random House, Inc., and Lippincott Williams & Wilkins. Dr. Frazier has received federal funding or research support from, acted as a consultant to, received travel support from, and/or received a speaker’s honorarium from the Simons Foundation, Ingalls Foundation, Forest Laboratories, Ecoeos, IntegraGen, Kugona LLC, Shire Development, Bristol-Myers Squibb, National Institutes of Health, and the Brain and Behavior Research Foundation. Dr. Fristad has received royalties from Guilford Press, American Psychiatric Press, and CFPSI Press. Dr. B. Goldstein is a consultant for BMS, has received research support from Pfizer, and has received speaker’s honoraria from Purdue Pharma. Dr. Hunt is a senior editor of Brown Child and Adolescent psychopharmacology update, and receives honoraria from Wiley Publishers. Dr. Keller receives research support from Pfizer, and has received honoraria from Medtronic. Dr. Strober receives support from the Resnick Endowed Chair in Eating Disorders. Dr. Youngstrom has consulted with Lundbeck and Otsuka. Dr. Arnold has received research funding from Curemark, Forest, Lilly, Neuropharm, Novartis, Noven, and Shire (as well as NIH and Autism Speaks) and has consulted with or been on advisory boards for Gowlings, Neuropharm, Novartis, Noven, Organon, Otsuka, Pfizer, Roche, Seaside Therapeutics, Sigma Tau, Shire, and Tris Pharma and received travel support from Noven. Dr. Findling receives or has received research support, acted as a consultant and/or served on a speaker’s bureau for Alexza Pharmaceuticals, American Academy of Child & Adolescent Psychiatry, American Physician Institute, American Psychiatric Press, AstraZeneca, Bracket, Bristol-Myers Squibb, Clinsys, Cognition Group, Coronado Biosciences, Dana Foundation, Forest, GlaxoSmithKline, Guilford Press, Johns Hopkins University Press, Johnson & Johnson, KemPharm, Lilly, Lundbeck, Merck, NIH, Novartis, Noven, Otsuka, Oxford University Press, Pfizer, Physicians Postgraduate Press, Rhodes Pharmaceuticals, Roche, Sage, Seaside Pharmaceuticals, Shire, Stanley Medical Research Institute, Sunovion, Supernus Pharmaceuticals, Transcept Pharmaceuticals, Validus, and WebMD.

Ethical standards

This study was reviewed and approved by the institutional review boards of all sites prior to the enrollment of any participant. This includes the IRBs of: (1) the Course and Outcome of Bipolar Youth (COBY) study (sites: University of Pittsburgh Medical Center, Brown University, and the University of California Los Angeles); (2) the Longitudinal Assessment of Manic Symptoms (LAMS; sites: University of Pittsburgh, Case-Western Reserve University, University of Cincinnati), and (3) Dr. Dickstein’s Pediatric Mood, Imaging, and NeuroDevelopment (PediMIND) studies. All participants gave their informed consent prior to inclusion in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dickstein, D.P., Axelson, D., Weissman, A.B. et al. Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder. Eur Child Adolesc Psychiatry 25, 625–638 (2016). https://doi.org/10.1007/s00787-015-0769-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00787-015-0769-2

Keywords

Search

Navigation