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Which tool is most useful in diagnosing bipolar disorder in children?
No single, well-validated screening instrument for clinical diagnosis of bipolar disorder in children exists. That said, the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), a semi-structured interview, along with clinical evaluation by a childhood mental health specialist, is used most frequently in major research studies (strength of recommendation [SOR]: C).
As a screening tool in the primary care setting, family history of bipolar disorder in either biologic parent increases the odds of diagnosis (SOR: A). High or low scores on parent-reported screening tests (Parent Young Mania Rating Scale [P-YMRS], Parent General Behavior Inventory [P-GBI], and Child Behavior Checklist [CBCL]) also significantly increase or decrease the likelihood of diagnosis (SOR: B).
Make sure it’s not ADHD
Adam J. Zolotor, MD, MPH
University of North Carolina at Chapel Hill
When evaluating a child for mental health, behavioral, or academic concerns, I always begin with an assessment targeting potential attention deficit hyperactivity disorder (ADHD). Distinguishing mania from hyperactivity and impulsivity is difficult. The most useful clue is family history. Suspicion of bipolar disorder (based on mood cycling or family history) would prompt me to refer to a child mental health specialist. Also, when I’m treating a child with ADHD, I consider alternate or comorbid conditions when he or she fails to achieve behavioral goals.
Of the rating scales reviewed above, I consider the P-GBI and the P-YMRS useful in risk stratification. However, screening instruments are less useful when a disease is rare (as with childhood bipolar disorder). Children with hyperactivity and impulsivity may have a range of conditions from hyperthyroidism to anxiety disorders, but we must listen to the history, observe the patient, and proceed with an evaluation based on the likelihood of disease.
Evidence summary
Retrospective analysis of 2 large cohort studies of adults with bipolar disorder indicated that at least 50% of these patients had an onset of illness before age 19, establishing support for the presence of bipolar disorder among children and adolescents.1 The criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cannot be easily applied to most children and adolescents with bipolar disorder because most do not meet the criteria for Bipolar I or II, but fall into the less well-defined category Bipolar NOS (not otherwise specified).2,3
Compared with adults, children and adolescents are more difficult to diagnose because they are less likely to have discrete episodes of mania, and instead present with severe irritability, rapid cycling, or mixed mania.2,4 In laddition, symptoms progress and evolve as children and adolescents grow.1 Comorbid disorders such as ADHD, oppositional defiant disorder, conduct disorder, and learning disorders are common in this population, further complicating diagnosis.2
Screening instruments are imperfect
Different versions of the KSADS have been used in most research studies on this disorder.2 Despite this, concerns about the validity of the instrument still exist because of lack of sufficient testing, vagueness of the diagnostic criteria, and the subjective nature of the test.5,6 Because specialized training is required to administer the test and testing can last a full day, its use in most office settings is impractical. It is also not meant as a stand-alone test, but to be used in conjunction with a clinical evaluation by a trained mental health professional.7
In a general clinical setting, family history and selected screening instruments may help to increase or decrease clinical suspicion for the disorder and guide referral for more specialized evaluation by a child mental health provider. In addition, a meta-analysis found that children or adolescents who have a biologic parent with bipolar disorder have 2 to 10 times the odds of being diagnosed with bipolar disorder.7
Three screening tests (CBCL, P-GBI, and P-YMRS) available for the office setting use parent-reported scores, and perform best when compared with KSADS as the standard.3 These instruments were associated with likelihood ratios that significantly improved the odds of diagnosis and could allow clinicians to stratify patients as high or low risk (TABLE).3
TABLE
Likelihood ratios for 3 screening tools you can use in the office
| For ages 5–10* | For ages 11–17† | |||||||
| IF THE SCORE IS… | IF THE SCORE IS… | |||||||
| LOW | MOD. LOW | HIGH | VERY HIGH | LOW | MOD. LOW | HIGH | VERY HIGH | |
| THEN THE LR FOR THE INSTRUMENT IS… | THEN THE LR FOR THE INSTRUMENT IS… | |||||||
| P-YMRS | 0.08 | 0.48 | 6.94 | 8.92 | 0.20 | 0 .32 | 4.07 | 7.41 |
| P-GBI | 0.10 | 0.48 | 4.90 | 6.29 | 0.06 | 0.25 | 4.82 | 9.21 |
| CBCL | 0.07 | 0.47 | 3.15 | 3.52 | 0.04 | 0.53 | 2.65 | 4.29 |
| * Population studied had a 50.3% prevalence of bipolar disorder. | † Population studied had a 40.7% prevalence of bipolar disorder. | |||||||
Recommendations from others
Two consensus conferences, a Canadian guideline, and a National Institute of Mental Health round-table all concluded that there is currently no ideal test for the diagnosis of child and adolescent bipolar disorder, but that such an instrument needed to be developed.2,5,6,8 One consensus conference further concluded that the diagnosis is best made by childhood mental health specialists based on multiple informants, such as the child and parents, with symptoms present in at least 2 settings or by direct observation.6
A Canadian consensus conference proposed screening patients with depressive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecific somatic symptoms or reverse vegetative symptoms (eg, hypersomnia and hyperphagia). Their recommendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8
1. Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006;67:115-125.
2. National Institute of Mental Health research round-table on prepubertal bipolar disorder J Am Acad Chld Adolesc Psychiatry 2001;40:871-878.
3. Youngstrom E, Findling R, Calabrese J, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry 2004;43:847-858.
4. Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002;23:42-56.
5. Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003;42:1494-1503.
6. Carlson G, Jensen P, Findling R, et al. Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003;13:13-27.
7. Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pediatric bipolar disorder. J Clin Child Adolesc Psychol 2005;34:433-448.
8. Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
No single, well-validated screening instrument for clinical diagnosis of bipolar disorder in children exists. That said, the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), a semi-structured interview, along with clinical evaluation by a childhood mental health specialist, is used most frequently in major research studies (strength of recommendation [SOR]: C).
As a screening tool in the primary care setting, family history of bipolar disorder in either biologic parent increases the odds of diagnosis (SOR: A). High or low scores on parent-reported screening tests (Parent Young Mania Rating Scale [P-YMRS], Parent General Behavior Inventory [P-GBI], and Child Behavior Checklist [CBCL]) also significantly increase or decrease the likelihood of diagnosis (SOR: B).
Make sure it’s not ADHD
Adam J. Zolotor, MD, MPH
University of North Carolina at Chapel Hill
When evaluating a child for mental health, behavioral, or academic concerns, I always begin with an assessment targeting potential attention deficit hyperactivity disorder (ADHD). Distinguishing mania from hyperactivity and impulsivity is difficult. The most useful clue is family history. Suspicion of bipolar disorder (based on mood cycling or family history) would prompt me to refer to a child mental health specialist. Also, when I’m treating a child with ADHD, I consider alternate or comorbid conditions when he or she fails to achieve behavioral goals.
Of the rating scales reviewed above, I consider the P-GBI and the P-YMRS useful in risk stratification. However, screening instruments are less useful when a disease is rare (as with childhood bipolar disorder). Children with hyperactivity and impulsivity may have a range of conditions from hyperthyroidism to anxiety disorders, but we must listen to the history, observe the patient, and proceed with an evaluation based on the likelihood of disease.
Evidence summary
Retrospective analysis of 2 large cohort studies of adults with bipolar disorder indicated that at least 50% of these patients had an onset of illness before age 19, establishing support for the presence of bipolar disorder among children and adolescents.1 The criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cannot be easily applied to most children and adolescents with bipolar disorder because most do not meet the criteria for Bipolar I or II, but fall into the less well-defined category Bipolar NOS (not otherwise specified).2,3
Compared with adults, children and adolescents are more difficult to diagnose because they are less likely to have discrete episodes of mania, and instead present with severe irritability, rapid cycling, or mixed mania.2,4 In laddition, symptoms progress and evolve as children and adolescents grow.1 Comorbid disorders such as ADHD, oppositional defiant disorder, conduct disorder, and learning disorders are common in this population, further complicating diagnosis.2
Screening instruments are imperfect
Different versions of the KSADS have been used in most research studies on this disorder.2 Despite this, concerns about the validity of the instrument still exist because of lack of sufficient testing, vagueness of the diagnostic criteria, and the subjective nature of the test.5,6 Because specialized training is required to administer the test and testing can last a full day, its use in most office settings is impractical. It is also not meant as a stand-alone test, but to be used in conjunction with a clinical evaluation by a trained mental health professional.7
In a general clinical setting, family history and selected screening instruments may help to increase or decrease clinical suspicion for the disorder and guide referral for more specialized evaluation by a child mental health provider. In addition, a meta-analysis found that children or adolescents who have a biologic parent with bipolar disorder have 2 to 10 times the odds of being diagnosed with bipolar disorder.7
Three screening tests (CBCL, P-GBI, and P-YMRS) available for the office setting use parent-reported scores, and perform best when compared with KSADS as the standard.3 These instruments were associated with likelihood ratios that significantly improved the odds of diagnosis and could allow clinicians to stratify patients as high or low risk (TABLE).3
TABLE
Likelihood ratios for 3 screening tools you can use in the office
| For ages 5–10* | For ages 11–17† | |||||||
| IF THE SCORE IS… | IF THE SCORE IS… | |||||||
| LOW | MOD. LOW | HIGH | VERY HIGH | LOW | MOD. LOW | HIGH | VERY HIGH | |
| THEN THE LR FOR THE INSTRUMENT IS… | THEN THE LR FOR THE INSTRUMENT IS… | |||||||
| P-YMRS | 0.08 | 0.48 | 6.94 | 8.92 | 0.20 | 0 .32 | 4.07 | 7.41 |
| P-GBI | 0.10 | 0.48 | 4.90 | 6.29 | 0.06 | 0.25 | 4.82 | 9.21 |
| CBCL | 0.07 | 0.47 | 3.15 | 3.52 | 0.04 | 0.53 | 2.65 | 4.29 |
| * Population studied had a 50.3% prevalence of bipolar disorder. | † Population studied had a 40.7% prevalence of bipolar disorder. | |||||||
Recommendations from others
Two consensus conferences, a Canadian guideline, and a National Institute of Mental Health round-table all concluded that there is currently no ideal test for the diagnosis of child and adolescent bipolar disorder, but that such an instrument needed to be developed.2,5,6,8 One consensus conference further concluded that the diagnosis is best made by childhood mental health specialists based on multiple informants, such as the child and parents, with symptoms present in at least 2 settings or by direct observation.6
A Canadian consensus conference proposed screening patients with depressive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecific somatic symptoms or reverse vegetative symptoms (eg, hypersomnia and hyperphagia). Their recommendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8
No single, well-validated screening instrument for clinical diagnosis of bipolar disorder in children exists. That said, the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), a semi-structured interview, along with clinical evaluation by a childhood mental health specialist, is used most frequently in major research studies (strength of recommendation [SOR]: C).
As a screening tool in the primary care setting, family history of bipolar disorder in either biologic parent increases the odds of diagnosis (SOR: A). High or low scores on parent-reported screening tests (Parent Young Mania Rating Scale [P-YMRS], Parent General Behavior Inventory [P-GBI], and Child Behavior Checklist [CBCL]) also significantly increase or decrease the likelihood of diagnosis (SOR: B).
Make sure it’s not ADHD
Adam J. Zolotor, MD, MPH
University of North Carolina at Chapel Hill
When evaluating a child for mental health, behavioral, or academic concerns, I always begin with an assessment targeting potential attention deficit hyperactivity disorder (ADHD). Distinguishing mania from hyperactivity and impulsivity is difficult. The most useful clue is family history. Suspicion of bipolar disorder (based on mood cycling or family history) would prompt me to refer to a child mental health specialist. Also, when I’m treating a child with ADHD, I consider alternate or comorbid conditions when he or she fails to achieve behavioral goals.
Of the rating scales reviewed above, I consider the P-GBI and the P-YMRS useful in risk stratification. However, screening instruments are less useful when a disease is rare (as with childhood bipolar disorder). Children with hyperactivity and impulsivity may have a range of conditions from hyperthyroidism to anxiety disorders, but we must listen to the history, observe the patient, and proceed with an evaluation based on the likelihood of disease.
Evidence summary
Retrospective analysis of 2 large cohort studies of adults with bipolar disorder indicated that at least 50% of these patients had an onset of illness before age 19, establishing support for the presence of bipolar disorder among children and adolescents.1 The criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cannot be easily applied to most children and adolescents with bipolar disorder because most do not meet the criteria for Bipolar I or II, but fall into the less well-defined category Bipolar NOS (not otherwise specified).2,3
Compared with adults, children and adolescents are more difficult to diagnose because they are less likely to have discrete episodes of mania, and instead present with severe irritability, rapid cycling, or mixed mania.2,4 In laddition, symptoms progress and evolve as children and adolescents grow.1 Comorbid disorders such as ADHD, oppositional defiant disorder, conduct disorder, and learning disorders are common in this population, further complicating diagnosis.2
Screening instruments are imperfect
Different versions of the KSADS have been used in most research studies on this disorder.2 Despite this, concerns about the validity of the instrument still exist because of lack of sufficient testing, vagueness of the diagnostic criteria, and the subjective nature of the test.5,6 Because specialized training is required to administer the test and testing can last a full day, its use in most office settings is impractical. It is also not meant as a stand-alone test, but to be used in conjunction with a clinical evaluation by a trained mental health professional.7
In a general clinical setting, family history and selected screening instruments may help to increase or decrease clinical suspicion for the disorder and guide referral for more specialized evaluation by a child mental health provider. In addition, a meta-analysis found that children or adolescents who have a biologic parent with bipolar disorder have 2 to 10 times the odds of being diagnosed with bipolar disorder.7
Three screening tests (CBCL, P-GBI, and P-YMRS) available for the office setting use parent-reported scores, and perform best when compared with KSADS as the standard.3 These instruments were associated with likelihood ratios that significantly improved the odds of diagnosis and could allow clinicians to stratify patients as high or low risk (TABLE).3
TABLE
Likelihood ratios for 3 screening tools you can use in the office
| For ages 5–10* | For ages 11–17† | |||||||
| IF THE SCORE IS… | IF THE SCORE IS… | |||||||
| LOW | MOD. LOW | HIGH | VERY HIGH | LOW | MOD. LOW | HIGH | VERY HIGH | |
| THEN THE LR FOR THE INSTRUMENT IS… | THEN THE LR FOR THE INSTRUMENT IS… | |||||||
| P-YMRS | 0.08 | 0.48 | 6.94 | 8.92 | 0.20 | 0 .32 | 4.07 | 7.41 |
| P-GBI | 0.10 | 0.48 | 4.90 | 6.29 | 0.06 | 0.25 | 4.82 | 9.21 |
| CBCL | 0.07 | 0.47 | 3.15 | 3.52 | 0.04 | 0.53 | 2.65 | 4.29 |
| * Population studied had a 50.3% prevalence of bipolar disorder. | † Population studied had a 40.7% prevalence of bipolar disorder. | |||||||
Recommendations from others
Two consensus conferences, a Canadian guideline, and a National Institute of Mental Health round-table all concluded that there is currently no ideal test for the diagnosis of child and adolescent bipolar disorder, but that such an instrument needed to be developed.2,5,6,8 One consensus conference further concluded that the diagnosis is best made by childhood mental health specialists based on multiple informants, such as the child and parents, with symptoms present in at least 2 settings or by direct observation.6
A Canadian consensus conference proposed screening patients with depressive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecific somatic symptoms or reverse vegetative symptoms (eg, hypersomnia and hyperphagia). Their recommendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8
1. Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006;67:115-125.
2. National Institute of Mental Health research round-table on prepubertal bipolar disorder J Am Acad Chld Adolesc Psychiatry 2001;40:871-878.
3. Youngstrom E, Findling R, Calabrese J, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry 2004;43:847-858.
4. Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002;23:42-56.
5. Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003;42:1494-1503.
6. Carlson G, Jensen P, Findling R, et al. Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003;13:13-27.
7. Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pediatric bipolar disorder. J Clin Child Adolesc Psychol 2005;34:433-448.
8. Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
1. Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006;67:115-125.
2. National Institute of Mental Health research round-table on prepubertal bipolar disorder J Am Acad Chld Adolesc Psychiatry 2001;40:871-878.
3. Youngstrom E, Findling R, Calabrese J, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry 2004;43:847-858.
4. Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002;23:42-56.
5. Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003;42:1494-1503.
6. Carlson G, Jensen P, Findling R, et al. Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003;13:13-27.
7. Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pediatric bipolar disorder. J Clin Child Adolesc Psychol 2005;34:433-448.
8. Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
Evidence-based answers from the Family Physicians Inquiries Network