In clinical samples, juvenile bipolar disorder (JBPD) is frequently accompanied by co-morbid attention-deficit/hyperactivity disorder (ADHD). Clinical trials assessing combined psychopharmacological interventions in this population are scarce, and methylphenidate (MPH) may worsen manic symptoms. We conducted a randomized crossover trial with MPH and placebo (2 weeks each) combined with aripiprazole in children and adolescents (n = 16; 8-17 years old) with JBPD and ADHD who had a significant response in manic symptoms with aripiprazole but still presented clinically significant symptoms of ADHD. ADHD, manic, and depressive symptoms were assessed by means of standard scales. Fourteen out of the 16 subjects completed the trial. No significant differences between the effects of methylphenidate and placebo were detected in ADHD (F(1, 43.22) = 0.00; p = 0.97) or manic (F(1, 40.19) = 0.93; p = 0.34) symptoms. Significant improvement in depressive symptoms was observed in the MPH group (F(1,19.03) = 7.75; p = 0.01) according to a secondary self-reported outcome measure. One patient using aripiprazole and MPH discontinued the trial due to the onset of a severe mixed episode. No other significant adverse events were observed. Although MPH did not worsen manic symptoms, it was not more effective than placebo in improving ADHD symptoms in children and adolescents with JBPD co-morbid with ADHD stabilized with aripiprazole. Further investigations are warranted. This study is registered at www.clinicaltrials.gov under the identifier NCT00305370.

Attention-deficit/hyperactivity disorder (ADHD) seems to be associated with significant psychosocial adversity. However, few studies assessed the role of environmental, social and interpersonal factors specifically in ADHD, inattentive type (ADHD-I). Thus, this study aims to investigate whether family environment risk factors are associated with ADHD-I. In a case-control study, we assessed a non-referred sample of 100 children and adolescents with ADHD-I and 100 non-ADHD controls (6-18 years old). They were systematically evaluated through structured diagnostic interviews. The following family adversity measures were used: Rutter's family adversity index (marital discord, low social class, large family size, paternal criminality, maternal mental disorder), Family Environment Scale (FES) (subscores of cohesion, expressiveness and conflict) and Family Relationship Index (FRI) (based on the subscores above). After adjusting for confounding factors (social phobia and maternal history of ADHD), the odds ratio (OR) for ADHD-I increased as the number of Rutter's indicators increased. Families of children with lower FES cohesion subscores presented higher OR for ADHD-I (OR 1.24; 95% confidence interval 1.05-1.45). Lower levels of FRI, a general index of family relationship, were also related to higher risk of ADHD-I (OR 1.11; 95% confidence interval 1.03-1.21). Our findings suggest that family adversity (in general), low family cohesion and low FRI (in particular) are associated with an increase in the risk for ADHD-I. However, the cross-sectional nature of the study limits our ability to infer causality.

clinicaltrials.gov Identifier: NCT00116259.