A recent study  was carried out in 140 adolescent offspring, aged 12-21 years, of bipolar parents living in the Netherlands, 41 of whom (29%) met diagnostic criteria for at least one current DSM-IV mental disorder. The most frequent diagnoses were mood disorder (14%, including 3% with a bipolar disorder), anxiety disorder (8%), substance use disorder (6%), ADHD (4%) and disruptive behaviour disorder (4%). A total of 61 subjects (44%) met criteria for at least one lifetime diagnosis, namely mood disorder (27%, including 3% with bipolar disorder), anxiety disorder (11%), substance use disorder (6%), disruptive behaviour disorder (6%) and ADHD (5%). The Child Behavior Checklist (CBCL)  was used in these subjects and in controls from the general population, to assess behavioural and emotional problems, according to self-rating as well as parents' and teachers' evaluation. Higher scores were found for 8 of the 11 subscales of the self-administered CBCL (mostly concerning internalizing problems) in the female probands, and for 4 of the 11 subscales (mostly concerning externalizing problems such as aggressive behaviour) in the male probands. According to teachers' evaluation, there was no significant difference between probands and controls. Overall, this study reported lower rates of psychopathology (in terms of DSM-IV diagnoses, as well as in terms of dimensional scores), compared with those found in studies from US populations. These rates were only slightly different from those found in the general Dutch population with a similar procedure by the same research group . Only the prevalence of mood disorders in the probands was considerably higher than that found in the general population. These findings cast doubts on the previously established conclusion that the adolescent offspring of bipolar patients are at great risk for psycho-pathology in general, and specifically for bipolar disorder. According to the authors, the difference between their results and those of US studies may be in part due to the modalities of sample recruitment, which may have selected less impaired bipolar parents (two-thirds of the sample were recruited from patients' associations and only one-third from outpatient clinics). However, this hypothesis is not supported by their own data, since differences between the two patient subgroups did not reach statistical significance. Another possible selection bias is related to the fact that only a minority of selected parents agreed to participate, so that the most impaired subjects or the families with the most severely impaired offspring may have been excluded from the study. The Dutch authors also hypothesize that a more frequent use of antidepressants and stimulants in the USA may account for higher rates of pharmacological hypomania. Finally, another possibly relevant factor may be the different conceptualization of bipolar disorder in the USA and in Europe.
European and US conceptualizations of mania in prepubertal children have been summarized recently by Harrington and Myatt , who express doubt about the validity of the diagnosis of mania, and particularly about the inferences made about the meaning of some symptoms. According to this view, manic states in prepubertal children are extremely rare. However, the experience of one of the authors of this chapter [52,58] is that paediatric, including prepubertal, mania is common in Italy, and exhibits the same range of comorbidities as reported in the USA.
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