Bibliography for Pediatric Bipolar Disorder

.1 99

.5 95

1000 1 90 500

2 200 80 100 50 70 5 20 60

10 10 50 5 40 20 2 30 % 1 % 30 .50 20 40 .20 50 .10 10 60 .05 5 70 .02 .01 80 .005 2 .002 90 .001 1

95 .5

99 .1 Pretest Probability Likelihood Ratio Posttest Probability EBA FOR DIAGNOSIS AND TREATMENT 36

Table 1 Twelve Steps in Implementing Evidence-Based Assessment and Applying It to Individual Cases Assessment Step Rationale Steps to Put in Practice A. Identify most common Planning for the typical issues helps ensure that appropriate Review practice database, notes, reports; generate “short list” of diagnoses in our setting assessment tools are available and routinely used most common diagnoses and clinical issues B. Benchmark base rates Base rate is an important starting point to anchor evaluations Select a sample of cases (six months, random draw from past and prioritize order of investigation year) and tally local base rate; compare to benchmarks from other practices and published rates; identify any potential mismatches C. Evaluate risks and Risk factors raise “index of suspicion,” and the combination Make short checklist of key risk factors; make second list of moderators of multiple risk factors elevate probability into “assessment” factors that might change treatment selection or moderate or possibly “treatment” zones outcome; develop plan for how to routinely assess them D. Synthesize intake instruments Probably already using in practice; upgrading the value for Make a table crossing assessment instruments with common into revised probabilities formulation and decision-making by clarifying what the presenting problems. Identify gaps in coverage. Make cheat sheet scores mean vis changing probability for common conditions with key information about assessment for each application. E. Interpret cross-informant data High scores across settings or informants often mean worse Gather collateral information to revise case formulation; consider patterns pathology; do not over-interpret common patterns. parent, spouse, roommate; also behavioral traces such as Facebook postings. Anticipate typical level of agreement. F. Add narrow and incremental Often more specific measures will show better validity, or Have follow-up tests available and criteria for when they should assessments to clarify incremental value supplementing broad measures be used. Organize so that key information is easy to integrate diagnoses G. Add necessary intensive If screening and risk factors put revised probability in the Do (semi-)structured interview or review checklist with client to methods to finalize diagnoses “assessment zone,” what are the evidence-based methods to confirm sufficient criteria; supplement with other methods as and formulation confirm or rule out the diagnosis in question? needed to cross treatment threshold. H. Finish assessment for Rule out general medical conditions, other medications; Develop systematic ways of screening for medical conditions and treatment planning and goal family functioning, quality of life, personality, school medication use. Assess family functioning, personality, setting adjustment, comorbidities also must be considered comorbidity, SES and other potential treatment moderators. I. Measure processes Check learning of therapy skills, evidence of early response Track homework, session attendance, life charts, mood check-ins (“dashboards, quizzes and or need for change in intervention at each visit, medication monitoring, therapy assignments, daily homework”) report cards (Weisz et al., 2011). J. Chart progress and outcome Repeat assessment with main severity measures – interview Make cheat sheet with Jacobson & Truax (1991) benchmarks for (“midterm and final exams”) and/or parent report most sensitive to treatment effects; if measures routinely used; track homework, progress on skills; poor response, revisit diagnoses. Youth Top Problems (Weisz et al., 2011). K. Monitor maintenance; relapse Consolidating treatment gains and planning for maintenance Develop list of key predictors, recommendations about next warnings are core features of excellent termination planning, and action if starting to worsen. crucial to long term management of many problems L. Seek and use client Client beliefs and attitudes influence treatment seeking and Assess client concordance with treatment plan; ask about cultural preferences engagement, and are vital for balancing risks and benefits. factors that might affect treatment plan and engagement

EBA FOR DIAGNOSIS AND TREATMENT 37

Table 2 Benchmarks from Epidemiological Studies and Medicaid Surveillance NCS-R Diagnosis or Target All Ages 18-29 30-44 45-49 60+ NCS-A SAMHSA Rettew et Rettew Condition Years* Years Years Years Medicaid al. (2009) clinical Data SDI Any Disorder 46% 52% 55% 47% 26% >99% -- -- Any Anxiety 29% 30% 35% 31% 15% 32% ------Specific Phobia 12% 13% 14% 14% 7% 19% -- 15% 6% PTSD 7% 6% 8% 9% 3% 5% -- 9% 3% Generalized Anxiety 6% 4% 7% 8% 4% 2% -- 10% 5% Disorder Panic Disorder 5% 4% 6% 6% 2% 2% -- 11% 12% Social Phobia 5% 14% 14% 12% 7% 9% -- 20% 6% Separation Anxiety 5% 2% 2% 1% 1% 8% -- 18% 8% Any Impulse 25% 27% 23% -- -- 20% ------Control Disorder ODD 9% 10% 8% -- -- 13% -- 38% 37% Conduct Disorder 9% 11% 8% -- -- 7% 5% 25% 17% ADHD 8% 8% 8% -- -- 9% 18% 38% 23% Intermittent 5% 7% 6% 5% 2% ------Explosive Disorder Any Mood Disorder 21% 21% 25% 23% 12% 14% 20% -- -- MDD 17% 15% 20% 19% 11% 12% -- 26% 17% Bipolar I & II 4% 6% 5% 4% 1% 3% ------Dysthymia 3% 2% 3% 4% 1% (included -- 8% 10% above) Any Substance 15% 17% 18% 15% 6% 11% 53% 30% 20% Abuse Disorder Note. Statistics adapted from (Kessler, Berglund, Demler, Jin, & Walters, 2005; Merikangas et al., 2010; Substance Abuse and Mental Health Services Administration, 2012). EBA FOR DIAGNOSIS AND TREATMENT 38

Table 3 Scores and Interpretive Information for Applying EBA Approach to Lea (18 year old White female presenting to an outpatient clinic) Broad Measure (Step D) Cross-Informant (Step E) Treatment Phase Common Starting Scale & DLR Revised Next Test DLR Revised Confirmation Process Outcome Maintenance b Diagnostic Probability Score (Source) Probability Score (Source) Probability (Step G) (Step I) (Step J) (Step K) (Step B) Hypotheses (Step A) Depression 21% YSR T 2.43 39% CBC Internal 0.90 (E. A. 37% MINI (Sheehan et Youth Top Beck Worsening of Internal: 73 (local data) Raw: 14 Youngstro al., 1998): Problems Depression mood or energy m, 2013b) Major Depressive (Weisz et Inventory symptoms Episode al., 2011) (Beck & Steer, 1987)

Hypomania/Mania a YSR T 1.15 37% CBC T 0.53 16% MINI: Hypomanic Smartphone 32% External: 61 External 56 Episode mood app “ ” (Youngstro (Youngstro Bipolar II m et al., m et al., 2004) 2004)

ADHD 8% YSR T 1.36 11% CBC T 2.19 21%c MINI: ADHD CAARS CAARS Monitor Attention Attention (local data) Predominantly schoolwork Probs: 78 (local data) Probs: 70 Inattentive Type completion rate

Anxiety 29% YSR T 2.35 49% CBC T 0.98 48% Not a Internal: 73 Internal 63 -- -- primary -- (Van Meter (Van Meter focus et al., under et al., under review) review)

Substance Issues 15% YSR #2: 0 3.4 37% CBC #2: 0 5.6 77% MINI: Substance Check in at Not agreed as Contact (local data) (local data) Abuse – past therapy a treatment therapist if YSR #99: 2 CBC #99: 1 cannabis and sessions goal usage back at Xanax TM abuse prior level YSR #105: 1.5 CBC #105: 1 (marijuana) a Our starting probability was based on the prevalence of bipolar spectrum disorder in the NCS in Lea’s age range (6%, see Table 2), then adjusted for the history of bipolar disorder in a first degree relative (DLR = 5.0), resulting in a revised probability of 32% (see marked up nomogram in Figure 2; Step C). b Readers can compare their impressions based on the presenting problem and test scores with the EBA estimates in this column. The estimates often are different, but the EBA approach is much more consistent across sets of clinicians as well as often being less biased (Jenkins et al., 2011). c We could replace the CBC and YSR with the CAARS scores, as the CAARS provides more coverage of ADHD symptoms, and more information about severity (Step F). Van Voorhees et al. (2011) report that the combination of CAARS T >65 from both self and observer had a DLR 2.6 for the inattentive subtype. Combining the initial base rate estimate of 8% for ADHD with a DLR of 2.6 yields a revised probability of 18%, essentially confirming the estimate of 21% obtained via the CBC and YSR. Note. Steps H (finish treatment planning and goal setting) and L (seek and use client preferences) are discussed in text though not mentioned in Table 3. EBA FOR DIAGNOSIS AND TREATMENT 39 Assessment: Assess factors that might Figure 1. Mapping Assessment Results onto Clinical Decision-Making 100% moderate treatment (H). High Monitor process & adherence Note. Letters refer to assessment step in Table 1. Probability/ (I). Measure “midterm” for Acute treatment adjustment and Treatment “final” for outcomes (J). Relapse monitoring (K). Zone Treatment: E, F. Acute Interventions (intensive More High score therapy, medication, A. Make List of Specific Test-Treat Threshold Clinical Hypotheses, + High risk hospitalization). Negotiate Yes, risk factors Scales and Rank by Starting treatment selection to include Probability patient preferences (L) Moderate Assessment: High score: Use more cross-informant data Replace or combine Probability/ Pick One Assessment (E), specific measures (F), semi- with more specific structured interviews & (Repeat, measure High score Zone as needed) + Low risk supplemental testing (G) to (and gather enough data to confirm or Secondary disconfirm diagnosis.

B. Base C. Risk D, E. Intervention) Treatment: Rate of Factors? No Broad Secondary interventions and

Target Scales non-specific + low risk treatments; psychotherapy; selective prevention

Low score Test-Wait Threshold Assessment: + High risk Low No further assessment for disorder unless there is a new Probability/ risk factor or change in status Low score, Wait Zone (K) No risk factors (and Primary Treatment: Prevention) Target diagnosis ruled out. 0% Treat any other conditions; Posterior consider primary preventions Probability Supplemental Handout Page 1

Changes in Likelihood of a Bipolar Diagnosis as a Function of Scale Scores

Age 5-10 Likelihood Ratios (LR) – 50.3% prevalence of bipolar disorders

Summary Range: Low Mod. Low Neutral Mod. High High Very High

P-YMRS Score <7 7 to 13 14 to 21 22 to 29 30 to 34 35+

LR .08 .48 .88 2.78 6.94 8.92

P-GBI Score <11 11 to 20 21 to 30 31 to 42 43 to 50 51+

LR .10 .48 1.34 2.31 4.90 6.29

CBCL Score <58 58 to 67 68 to 72 73+

LR .07 .47 1.50 3.91

TRF Score <49 49 to 56 57 to 62 63 to 70 71+

LR .75 .80 .88 1.22 1.51

Age 11-17 Likelihood Ratios (LR) – 40.7% prevalence of bipolar disorders

Measure Range: Low Mod. Low Neutral Mod. High High Very High

P-YMRS Score <6 6 to 11 12 to 17 18 to 23 24 to 27 28+

LR .20 .32 .99 1.99 4.07 7.41

P-GBI Score <9 9 to 15 16 to 24 25 to 39 40 to 48 49+

LR .06 .25 1.12 2.22 4.82 9.21

A-GBI Score <10 10 to 37 38 to 45 46+

LR .33 .99 2.02 3.92

CBCL Score <54 54 to 64 65 to 69 70 to 75 76 to 80 81+

LR .04 .53 1.26 2.14 2.65 4.29

YSR Score <49 49 to 55 56 to 62 63 to 69 70 to 76 77+

LR .31 .52 1.15 1.58 2.32 3.03

TRF Score <46 46 to 53 54 to 60 61 to 76 77+

LR .25 .64 .98 1.79 3.76

Note: P-YMRS Total Score, P-GBI and A-GBI Hypomanic/Biphasic score (sum of 28 items scored 0-3), CBCL/TRF/YSR Externalizing T-Scores.

Youngstrom, E. A., Findling, R. L., Calabrese, J. R., Gracious, B. L., Demeter, C., DelPorto Bedoya, D., et al. (2004). Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. Journal of the American Academy of Child & Adolescent Psychiatry. Adapted from Table 4.

Child and Adolescent Bipolar Disorder Workshop Eric Youngstrom, Ph.D. University of North Carolina at Chapel Hill [email protected] Davie Hall, Chapel Hill, NC 27599-3270

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Table 3 Base rates of PBD in different clinical settings

Setting (Reference) Base Rate Demography Diagnostic Method

High school epidemiological 0.6% Northwestern USA high KSADS-PL y (Lewinsohn et al., 2000) school

Community Mental Health Center 6% Midwestern Urban, 80% non- Clinical interview & treatment p,y (E. A. Youngstrom et al., 2005) white, low-income

General Outpatient Clinic; 6% to 8% Urban academic research WASH-U-KSADS p,y (B. Geller, Zimerman, Williams, Delbello, Frazier et al., 2002) centers

County Wards (DCFS) 11% State of Illinois Clinical interview & treatment y (Naylor et al., 2002, October)

Specialty Outpatient Service (Biederman et al., 1996) 15-17% New England KSADS-E p,y (only p young)

Incarcerated adolescents 2% Midwestern Urban DISC y (Teplin, Abram, McClelland, Dulcan, & Mericle, 2002)

Incarcerated adolescents (Pliszka et al., 2000) 22% Texas DISC y

Acute psychiatric hospitalizations in 2002-2003 – adolescents (Blader & Carlson, 21% All of U.S.A. Centers for Disease Control survey of 2006) discharge diagnoses

Inpatient service (Carlson & Youngstrom, 2003) 30% manic sx, New York City Metro Region DICA; KSADS p,y <2% strict BP I

Acute psychiatric hospitalizations in 2002-2003 – children (Blader & Carlson, 40% All of U.S.A. Centers for Disease Control survey of 2006) discharge diagnoses p Parent interviewed as component of diagnostic assessment; y youth interviewed as part of diagnostic assessment. Note: KSADS = Kiddie Schedule for Affective Disorders and Schizophrenia, PL = Present and Lifetime version, WASH-U = Washington University version, -E = Epidemiological version of the KSADS; DISC = Diagnostic Interview Schedule for Children; DICA = Diagnostic Interview for Children and Adolescents. Table modified from Table 1 in Youngstrom, Findling, et al. (2005).

Child and Adolescent Bipolar Disorder Workshop Eric Youngstrom, Ph.D. University of North Carolina at Chapel Hill [email protected] Davie Hall, Chapel Hill, NC 27599-3270

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Table 4 Areas Under the Curve (AUCs) and Likelihood Ratios for Potential Screening Measures for PBD

Screening Measure AUC LR+ LR- (Score) Citation Clinically Generalizability (Primary Reference) (Score)

Adolescents (11 to 18 years) CBCL Externalizing T-Score (Achenbach, .78 (N=324) 4.3 (81+) .04 (<54) (E. A. Youngstrom, Findling, High: Bipolar Spectrum Disorder (BPSD) versus 1991a) Calabrese et al., 2004) all other diagnoses presenting to academic outpatient clinic, excluding pervasive developmental disorders and IQ < 80. TRF Externalizing T-Score (Achenbach, .70 (N=324) 3.8 (77+) .25 (<46) (E. A. Youngstrom, Findling, “ ” 1991b) Calabrese et al., 2004) YSR Externalizing T-Score (Achenbach, .71 (N=324) 3.0 (77+) .31 (<49) (E. A. Youngstrom, Findling, “ ” 1991c) Calabrese et al., 2004) Parent General Behavior Inventory -- .84 (N=324) 9.2 (49+) .06 (<9) (E. A. Youngstrom, Findling, “ ” Hypomanic/Biphasic (E. A. Youngstrom, Calabrese et al., 2004) Note: Uses 0 to 3 scoring Findling, Danielson, & Calabrese, 2001) Parent Young Mania Rating Scale .80 (N=324) 7.4 (28+) .20 (<6) (E. A. Youngstrom, Findling, “ ” (Gracious et al., 2002) Calabrese et al., 2004) Note: Uses 0 to 4, 0 to 8 scoring as per Young et .70 (N=124) al. (1978) (E A Youngstrom et al., 2005) Adolescent General Behavior Inventory – .62 3.9 (46+) .33 (<10) (E. A. Youngstrom, Findling, “ ” Hypomanic/Biphasic (N=324) Calabrese et al., 2004) Note: Uses 0 to 3 scoring (Depue et al., 1981) .65 (E A Youngstrom et al., (N=124) 2005) Parent Mood Disorder Questionnaire ~.84 3.9 (5+) .32 (<5) (Wagner et al., 2006) High (Wagner, Findling, Emslie, Gracious, & (N<150) Note: Algorithm used by Wagner et al. (2006) Reed, 2006) required co-occurring and at least moderate .75 (N=124) (E A Youngstrom et al., impairment 2005) Adolescent Mood Disorder Questionnaire ~.59 1.5 (5+) .84 (<5) (Wagner et al., 2006) Note: Hirschfeld’s algorithm required co- (Hirschfeld et al., 2000a) (N< 150) occurring and at least moderate impairment; Youngstrom et al. (2005) and Wagner (2006) both .63 (N=124) (E A Youngstrom et al., found sensitivity improved by waiving these 2005) requirements Adolescent Young Mania Rating Scale -- .50 (N=124) -- -- (E A Youngstrom et al., Very High – BPSD vs. all others at community Questionnaire 2005) mental health center (E A Youngstrom et al., 2005) Note: Do not use clinically!

Child and Adolescent Bipolar Disorder Workshop Eric Youngstrom, Ph.D. University of North Carolina at Chapel Hill [email protected] Davie Hall, Chapel Hill, NC 27599-3270

Supplemental Handout Page 4

Children (5 to 10 years) CBCL Externalizing T-Score (Achenbach, .82 (N=318) 3.7 (73+) .07 (<58) (E. A. Youngstrom, Findling, High: BPSD versus all other diagnoses presenting 1991a) Calabrese et al., 2004) to academic outpatient, excluding pervasive developmental disorders and IQ < 80. TRF Externalizing T-Score (Achenbach, .57 (N=318) 1.4 (63+) .78 (<57) (E. A. Youngstrom, Findling, “ ” 1991b) Calabrese et al., 2004) Note: Do not use clinically! Parent General Behavior Inventory -- .81 (N=318) 6.3 (51+) .10 (<11) (E. A. Youngstrom, Findling, “ ” Hypomanic/Biphasic (E. A. Youngstrom et Calabrese et al., 2004) Note: Uses 0 to 3 scoring al., 2001) Parent Young Mania Rating Scale .83 (N=318) 8.9 (35+) .08 (<7) (E. A. Youngstrom, Findling, “ ” (Gracious et al., 2002) Calabrese et al., 2004) Note: Uses 0 to 4, 0 to 8 scoring as per Young et .66 (N=141) al., 1978 (E A Youngstrom et al., 2005) Parent Mood Disorder Questionnaire .72 (N=141) -- -- (E A Youngstrom et al., Very High – BPSD vs. all others at community (Wagner et al., 2006) 2005) mental health center

Combined Samples (Child & Adolescent Not Reported Separately) Parent Child Mania Rating Scale .91 13.7 (20+) .19 (<20) (Pavuluri et al., 2006) Limited: 50 BPSD vs. 50 ADHD without mood (Pavuluri et al., 2006) (N=100) Two Item Screen .85 (N=264) 5.2* .31* (Tillman & Geller, 2005) * Tillman and Geller recommend cutting at 9+ for (Tillman & Geller, 2005) 1.6** .32** ages 7-8 years, 8+ for 9-10 years, and 6+ for ages .70 (N=500) (E A Youngstrom, Meyers, 11 to 17 years. Youngstrom, Calabrese, & ** Threshold was chosen to be statistically optimal Findling, 2006) for entire sample. Child Bipolar Questionnaire (Papolos & Not reported 7.1 N/A (Papolos, Hennen, Limited: KSADS validation group comprised of Papolos, 2002) (N=135) Cockerham, Thode, & bipolar spectrum, ADHD, or no diagnosis. Youngstrom, 2006) Child Symptom Inventory (Parent) No relevant data published Adolescent version includes mania scale with (Gadow & Sprafkin, 1994) yet DSM-IV items; mania items added to research version of child instrument (available from CSI authors upon request) Adolescent Symptom Inventory (Gadow & No relevant data published Includes mania scale with DSM-IV items Sprafkin, 1997) yet Teacher Symptom Inventory (Gadow & No relevant data published Includes mania scale with DSM-IV items Sprafkin, 1999) yet Note: All studies used some version of KSADS interview by a trained rater, combined with review by a clinician to establish consensus. “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000). Adapted from Youngstrom, E.A. (in press). Pediatric bipolar disorder. In Mash, E. & Barkley, R. (Eds.), Assessment of childhood disorders, 4th ed. New York: Guilford Press.

Child and Adolescent Bipolar Disorder Workshop Eric Youngstrom, Ph.D. University of North Carolina at Chapel Hill [email protected] Davie Hall, Chapel Hill, NC 27599-3270

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Table 8. Clinically Significant Change Benchmarks with Common Instruments and Mood Rating Scales. Adapted from Youngstrom, E.A. (in press). Pediatric bipolar disorder. In Mash, E. & Barkley, R. (Eds.), Assessment of childhood disorders, 4th ed. New York: Guilford Press.

Cut Scores* Critical Change (Unstandardized Scores)

Measure A B C 95% 90% SEdifference

Benchmarks Based on Published Norms Beck Depression Inventory BDI Mixed Depression 4 22 15 9 8 4.8 CBCL T-Scores (2001 Norms) Total 49 70 58 5 4 2.4 Externalizing 49 70 58 7 6 3.4 Internalizing n/a 70 56 9 7 4.5 Attention Problems n/a 66 58 8 7 4.2 TRF T-Scores (2001 Norms) Total n/a 70 57 5 4 2.3 Ext n/a 70 56 6 5 3.0 Int n/a 70 55 9 7 4.4 Attention Problems n/a 66 57 5 4 2.3 YSR T-Scores (2001 Norms) Total n/a 70 54 7 6 3.3 Ext n/a 70 54 9 8 4.6 Int n/a 70 54 9 8 4.8 Benchmarks Based on Bipolar Spectrum Samples (Cooperberg, 2002) Young Mania Rating Scale (Clinician Rated) 6 2 2 12 10 6.2 Child Depression Rating Scale-Revised n/a 40 29 8 7 4.0 Parent GBI – Hypomanic/Biphasic Scale 7 19 15 8 7 4.2 Parent GBI – Depression Scale n/a 18 13 7 6 3.6 Adolescent GBI – Hypomanic/Biphasic Scale n/a 32 19 8 7 4.4 Adolescent GBI – Depression Scale n/a 47 27 10 9 5.2 * “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

Child and Adolescent Bipolar Disorder Workshop Eric Youngstrom, Ph.D. University of North Carolina at Chapel Hill [email protected] Davie Hall, Chapel Hill, NC 27599-3270

BRIEF CMRS, PARENT VERSION

Child’s name Date of Birth Case # / ID # (mm/dd/yy) INSTRUCTIONS

The following questions concern your child’s mood and behavior in the past month. Please place a check mark or an ‘x’ in a box for each item. Please consider it a problem if it is causing trouble and is beyond what is normal for your child's age. Otherwise, check 'rare or never' if the behavior is not causing trouble.

NEVER/ VERY SOMETIMES OFTEN Does your child . . . RARELY OFTEN

1. Have periods of feeling super happy for hours or days at a time, extremely wound up and excited, such as feeling 0 1 2 3 "on top of the world"

2. Feel irritable, cranky, or mad for hours or days at a time 0 1 2 3

3. Believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, 0 1 2 3 which causes trouble

4. Need less sleep than usual; yet does not feel tired the next day 0 1 2 3

5. Have periods of racing thoughts that his or her mind cannot slow down , and it seems that your child’s mouth 0 1 2 3 cannot keep up with his or her mind

6. Talk so fast that he or she jumps from topic to topic 0 1 2 3

7. Do many more things than usual, or is unusually productive or highly creative 0 1 2 3

8. Behave in a sexually inappropriate way (e.g., talks dirty, exposing, playing with private parts, masturbating, making sex phone calls, humping on 0 1 2 3 dogs, playing sex games, touches others sexually)

9. Have rage attacks, intense and prolonged temper 0 1 tantrums 2 3

10. Hear voices that nobody else can hear 0 1 2 3

TOTAL SCORE ______

Please send comments to: [email protected], [email protected] Relationship to child Date / / Study ID# T

Primary Care MDQ-P Instructions: Think about your child or adolescent and please answer each question as best as you can. 1. Has there ever been a period of time when your child was not his/her usual self and...... felt so good or so hyper that other people thought your child were not his/her normal self, Yes No or were so hyper that your child got into trouble? (circle yes or no for each line please) ...felt so irritable that he/she shouted at people or started fights or arguments? Yes No ...felt much more self-confident than usual? Yes No ...got much less sleep than usual and found he/she didn't really miss it? Yes No ...was much more talkative or spoke much faster than usual? Yes No ...thoughts raced through his/her head or your child couldn't slow his/her mind down? Yes No ...were so easily distracted by things around them that he/she had trouble concentrating or Yes No staying on track? ...had much more energy than usual? Yes No ...was much more active or did many more things than usual? Yes No ...was much more social or outgoing than usual; for example, telephoned friends in the Yes No middle of the night? ...was much more interested in sex than usual? Yes No ...did things that were unusual for him/her or that other people might have thought were Yes No excessive, foolish, or risky? ...spending money got him/her or your family into trouble? Yes No

2. If you checked YES to more than one of the above, have several of these ever happened Yes No during the same period of time? 3. How much of a problem did any of these cause your child -- like being unable to go to school; having

family, money, or legal troubles; getting into arguments or fights?

No Problem Minor Problem Moderate Problem Serious Problem

4. Please indicate whether any of your (blood) relatives have had any of these concerns: other than Grandparents Parents Aunts/Uncles Brothers/Sisters Children the child in this Suicide study Alcohol/Drug Problems Mental Hospital Depression Problems Manic or Bipolar

5. Has a health professional ever told you that you have manic-depressive illness or bipolar Yes No disorder?

Last Modified: 3/12/2007

Child’s name: Date:

Child’s age: Relationship to Child:

GENERAL BEHAVIOR INVENTORY Parent Version (P-GBI) Short Form – H/B (Revised Version, 2008)

Here are some questions about behaviors that occur in the general population. Think about how often they occur for your child. Using the scale below, select the number that best describes how often your child experienced these behaviors over the past year:

0 1 2 3 Never or Sometimes Often Very Often Hardly ever Almost Constantly

Keep the following points in mind:

Frequency: you may have noticed a behavior as far back as childhood or early teens, or you may have noticed it more recently. In either case, estimate how frequently the behavior has occurred over the past year.

For example: if you noticed a behavior when your child was 5, and you have noticed it over the past year, mark your answer “often” or “very often - almost constantly”. However, if your child has experienced a behavior during only one isolated period in his/her life, but not outside that period, mark your answer “never - hardly ever” or “sometimes”.

Duration: many questions require that a behavior occur for an approximate duration of time (for example, “several days or more”). The duration given is a minimum duration. If your child usually experiences a behavior for shorter durations, mark the question “never - hardly ever” or “sometimes”.

Changeability: what matters is not whether your child can get rid of certain behaviors if he/she has them, but whether these behaviors have occurred at all. So even if your child can get rid of these behaviors, you should mark your answer according to how frequently he/she experiences them.

Your job, then, is to rate how frequently your child has experienced a behavior, over the past year, for the duration described in the question. Please read each question carefully, and record your answer next to each question by placing an “X” in the appropriate box.

0 1 2 3 Never or Sometimes Often Very Often, Hardly ever Almost Constantly

0 1 2 3 1. Has your child experienced periods of several days or more when, although he/she was feeling unusually happy and intensely energetic (clearly more than your child’s usual self), he/she was also physically restless, unable to sit still, and had to keep moving or jumping from one activity to another?

2. Have there been periods of several days or more when your child’s friends or other family members told you that your child seemed unusually happy or high – clearly different from his/her usual self or from a typical good mood?

3. Has your child’s mood or energy shifted rapidly back and forth from happy to sad or high to low?

4. Has your child had periods of extreme happiness and intense energy lasting several days or more when he/she also felt much more anxious or tense (jittery, nervous, uptight) than usual (other than related to the menstrual cycle)?

5. Have there been times of several days or more when, although your child was feeling unusually happy and intensely energetic (clearly more than his/her usual self), he/she also had to struggle very hard to control inner feelings of rage or an urge to smash or destroy things?

6. Has your child had periods of extreme happiness and intense energy (clearly more than his/her usual self) when, for several days or more, it took him/her over an hour to get to sleep at night?

7. Have you found that your child’s feelings or energy are generally up or down, but rarely in the middle?

8. Has your child had periods lasting several days or more when he/she felt depressed or irritable, and then other periods of several days or more when he/she felt extremely high, elated, and overflowing with energy?

9. Have there been periods when, although your child was feeling unusually happy and intensely energetic, almost everything got on his/her nerves and made him/her irritable or angry (other than related to the menstrual cycle)?

10. Has your child had times when his/her thoughts and ideas came so fast that he/she couldn’t get them all out, or they came so quickly others complained that they couldn’t keep up with your child’s ideas? Total Score Interpretation Guide: 0 Minimal*; 1-4 Mild; 5-14 Neutral Risk; 15-17 High; 18+ Very High** risk *Minimal scores decrease likelihood of diagnosis by approximately 100 (LR = .01); Low scores by ~6 (LR = .16); Neutral does not change risk; High nearly triples risk (LR = 2.67) **Very High scores increase likelihood of diagnosis by approximately 7 (LR = 7.25) The likelihood of bipolar diagnosis is dependent on base rate of disorder in assessment setting. Please see Youngstrom, Frazier, Demeter, Calabrese, and Findling (2008) Journal of Clinical Psychiatry for additional information. Special thanks to Mark Cooperberg, Ph.D. Bibliography for Pediatric Bipolar Disorder

Assessment If you only read one article on assessment, this would be my pick: Youngstrom, E. A., Choukas-Bradley, S., Calhoun, C. D., & Jensen-Doss, A. (2014). Clinical guide to the Evidence-Based Assessment approach to diagnosis and treatment. Cognitive and Behavioral Practice. doi: 10.1016/j.cbpra.2013.12.005 The ideas in the 2014 CBP article integrate two separate papers, one focused on bipolar disorder (and going into a bit more detail about different measures), and the other laying out general principles for approaching assessment: Youngstrom, E.A., *Jenkins, M.M., Jensen-Doss, A., & Youngstrom, J.K. (2012). Evidence based assessment strategies for pediatric bipolar disorder. Israel Journal of Psychiatry, 49, 15-27. Special Issue: Pediatric Bipolar Disorder. Youngstrom, E. A. (2013). Future directions in psychological assessment: Combining Evidence-Based Medicine innovations with psychology's historical strengths to enhance utility. Journal of Clinical Child & Adolescent Psychology, 42, 139-159. doi: 10.1080/15374416.2012.736358 Specific Instruments or Issues in Assessment Algorta, G. P., Youngstrom, E. A., Phelps, J., Jenkins, M. M., Youngstrom, J. K., & Findling, R. L. (2013). An inexpensive family index of risk for mood issues improves identification of pediatric bipolar disorder. Psychological Assessment, 25, 12-22. doi: 10.1037/a0029225 Danielson, C. K., Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Discriminative validity of the General Behavior Inventory using youth report. Journal of Abnormal Child Psychology, 31, 29-39. Findling, R.L., Youngstrom, E.A., McNamara, N.K., Stansbrey, R., Demeter, C.A., Bedoya, D., Kahana, S.Y., & Calabrese, J.R. (2005). Early symptoms of mania and the role of parental risk. Bipolar Disorders, Special Issue: Pediatric Bipolar Disorder, 7, 623-634. Freeman, A. J., Youngstrom, E. A., Frazier, T. W., Youngstrom, J. K., Demeter, C., & Findling, R. L. (2012). Portability of a screener for pediatric bipolar disorder to a diverse setting. Psychological Assessment, 24, 341- 351. doi: 10.1037/a0025617 Jenkins, M. M., Youngstrom, E. A., Youngstrom, J. K., Feeny, N. C., & Findling, R. L. (2012). Generalizability of evidence-based assessment recommendations for pediatric bipolar disorder. Psychological Assessment, 24, 269- 281. doi: 10.1037/a0025775 Jenkins, M.M., Youngstrom, E.A., Washburn, J.J., & Youngstrom, J.K. (2011). Evidence-Based Strategies Improve Assessment of Pediatric Bipolar Disorder by Community Practitioners. Professional Psychology: Research and Practice, 42, 121-129. doi: 10.1037/a0022506 Youngstrom, E.A. (2007). Pediatric bipolar disorder. In Mash, E. & Barkley, R. (Eds.), Assessment of childhood disorders, 4th ed. New York: Guilford Press. Youngstrom, E. A., & Duax, J. (2005). Evidence Based Assessment of Pediatric Bipolar Disorder, Part 1: Base Rate and Family History. Journal of the American Academy of Child and Adolescent Psychiatry, 44(7), 712- 717. Youngstrom, E. A., & Kogos Youngstrom, J. (2005). Evidence Based Assessment of Pediatric Bipolar Disorder, Part 2: Incorporating Information from Behavior Checklists. Journal of the American Academy of Child and Adolescent Psychiatry, 44(8), 823-828. Youngstrom, E. A., Meyers, O. I., Demeter, C., Kogos Youngstrom, J., Morello, L., Piiparinen, R., Feeny, N. C., Findling, R. L., & Calabrese, J. R. (2005). Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings. Bipolar Disorders, 7, 507-517. Special Issue: Pediatric Bipolar Disorder.

Last Updated: 6/23/2014 Page 1 Youngstrom, E. A., Findling, R. L., Calabrese, J. R., Gracious, B. L., Demeter, C., DelPorto Bedoya, D., & Price, M.E. (2004). Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 847-858. Youngstrom, E. A., Findling, R. L., Youngstrom, J. K., & Calabrese, J. R., (2005). Towards an evidence-based assessment of pediatric bipolar disorder. Journal of Clinical Child and Adolescent Psychology, 34,433-448. Special Issue: Evidence-Based Assessment. Youngstrom, E.A., Meyers, O.I., Kogos Youngstrom, J., Calabrese, J.R., & Findling, R.L., (2006). Diagnostic and measurement issues in the assessment of pediatric bipolar disorder: Implications for understanding mood disorder across the life cycle. Development and Psychopathology, 18, 989-1021. Special issue: Bipolar Disorder (Guest Editors: David Miklowitz & Dante Cicchetti). Youngstrom, E.A., Findling, R.L., & Calabrese, J.R. (2004). Effects of adolescent manic symptoms on agreement between youth, parent, and teacher ratings of behavior problems. Journal of Affective Disorders, 82S, S5-S16. Youngstrom, E.A., Findling, R.L., Danielson, C.K., & Calabrese, J.R. (2001). Discriminative validity of parent report of hypomanic and depressive symptoms on the General Behavior Inventory. Psychological Assessment, 13, 267-276. Youngstrom, E. A., Frazier, T. W., Findling, R. L., & Calabrese, J. R. (2008). Developing a ten item short form of the Parent General Behavior Inventory to assess for juvenile mania and hypomania. Journal of Clinical Psychiatry, 69, 831-839. Youngstrom, E.A., Youngstrom, J.K., & Calabrese, J.R. (2006). Screening for bipolarity: A brief review of available measures and recommendations for future research. Aspects of Affect, 2, 1-6.

Epidemiology & Phenomenology Axelson, D.A., Birmaher, B., Findling, R.L., Fristad, M.A., Kowatch, R.A., Youngstrom, E.A., Arnold, L.E., Goldstein, B.I., Goldstein, T., Chang, K.D., DelBello, M.P., Ryan, N.D., & Diler, R.S. (2011). Concerns Regarding the Inclusion of Temper Dysregulation Disorder with Dysphoria in the DSM-5. Journal of Clinical Psychiatry, 72, 1257-1262. doi: 10.4088/JCP.10com06220 Axelson, D. A., Birmaher, B., Strober, M. A., Goldstein, B. I., Ha, W., Gill, M. K., . . . Keller, M. B. (2011). Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified. Journal of the American Academy of Child and Adolescent Psychiatry, 50(10), 1001-1016 e1003. doi: 10.1016/j.jaac.2011.07.005 Kowatch, R., Youngstrom, E.A., Danielyan, A., & Findling, R.L. (2005). Meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disorders, Special Issue: Pediatric Bipolar Disorder, 7, 483-496. Merikangas, K. R., & Pato, M. (2009). Recent developments in the epidemiology of bipolar disorder in adults and children: Magnitude, correlates, and future directions. Clinical Psychology: Science and Practice, 16, 121-133. doi: 10.1111/j.1468-2850.2009.01152.x Van Meter, A.R., Youngstrom, E.A., & Findling, R.L. (2012). Cyclothymic disorder: A critical review. Clinical Psychology Review,32, 229–243. doi:10.1016/j.cpr.2012.02.001 Van Meter, A.R., Moreira, A.L., & Youngstrom, E.A. (2011). Meta-analysis of epidemiological studies of pediatric bipolar disorder. Journal of Clinical Psychiatry, 72, 1250-1256.doi: 10.4088/JCP.10m06290 Van Meter, A.R., Youngstrom, E.A., Youngstrom, J.K., Feeny, N.C., & Findling, R.L. (2011). Examining the validity of cyclothymic disorder in a youth sample. Journal of Affective Disorders, 132, 55-63. doi: 10.1016/j.jad.2011.02.004 Van Meter, A. R., Youngstrom, E. A., Demeter, C., & Findling, R. L. (2012). Examining the validity of cyclothymic disorder in a youth sample: Replication and extension. Journal of Abnormal Child Psychology. doi: 10.1007/s10802-012-9680-1

Last Updated: 6/23/2014 Page 2 Youngstrom, E. A., Kogos Youngstrom, J., & Starr, M. (2005). Bipolar diagnoses in community mental health: Achenbach CBCL profiles and patterns of comorbidity. Biological Psychiatry, 58, 569-575. Youngstrom, E., Zhao, J., Mankoski, R., Forbes, R. A., Marcus, R. M., Carson, W., . . . Findling, R. L. (2013). Clinical significance of treatment effects with aripiprazole versus placebo in a study of manic or mixed episodes associated with pediatric bipolar I disorder. Journal of Child & Adolescent Psychopharmacology, 23, 72-79. doi: 10.1089/cap.2012.0024 Treatment Correll, C. U., Sheridan, E. M., & DelBello, M. P. (2010). Antipsychotic and mood stabilizer efficacy and tolerability in pediatric and adult patients with bipolar I mania: a comparative analysis of acute, randomized, placebo-controlled trials. Bipolar Disorders, 12, 116-141. doi: 10.1111/j.1399-5618.2010.00798.x Danielson, C. K., Feeny, N. C., Findling, R. L., & Youngstrom, E. A. (2004). Psychosocial treatment of bipolar disorder in adolescents: A proposed cognitive-behavioral intervention. Cognitive and Behavioral Practice, 11, 283-297. Findling, R.L., Frazier, T.W., Youngstrom, E.A., McNamara, N.K., Stansbrey, R., Gracious, B.L., Reed, M.D., Demeter, C.A., & Calabrese, J.R. (in press). Double blind, placebo-controlled trial of divalproex monotherapy in the treatment of sympotomatic youth at high risk for developing bipolar disorder. Journal of Clinical Psychiatry. Findling, R.L., McNamara, N.K., Gracious, B.L., Youngstrom, E.A., Stansbrey, R.J., Reed, M.D., Demeter, C.A., Branicky, L.A., Fisher, K.E., & Calabrese, J.R. (2003). Combination lithium and divalproex in pediatric bipolarity. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 895-901. Findling, R.L., McNamara, N.K., Youngstrom, E.A., Stansbrey, R., Gracious, B.L., Reed, M.D., & Calabrese, J.R. (2005). Double-blind 18-month trial of lithium versus divalproex maintenance treatment in children and adolescent with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 409- 417.

Fristad, M. A., & Macpherson, H. A. (2014). Evidence-based psychosocial treatments for child and adolescent bipolar spectrum disorders. Journal of Clinical Child and Adolescent Psychology, 43, 339-355. doi: 10.1080/15374416.2013.822309

Kowatch, R. A., Fristad, M. A., Birmaher, B., Wagner, K. D., Findling, R. L., & Hellander, M. (2005). Treatment guidelines for children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 213-235. McClellan, J., Kowatch, R., & Findling, R. L. (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 107-125. Web Resources for Families Balanced Mind Foundation (formerly the Child & Adolescent Bipolar Foundation) www.cabf.org Depression and Bipolar Support Alliance (formerly National Depressive & Manic Depressive Association) www.ndmda.org www.psychiatry24x7.com has a fair number of bipolar resources and links; sponsored by Janssen Pharmaceuticals

Resources For Children with Mood Disorders Brandon & the Bipolar Bear --T. Anglada My Bipolar, Roller Coaster, Feelings Book & Workbook—B. Hebert The Storm in My Brain -- Child & Adolescent Bipolar Foundation (CABF): 1-847-256-8525, www.bpkids.org

Last Updated: 6/23/2014 Page 3 Kid Power Tactics for Dealing with Depression -- N. & S. Dubuque Matt, The Moody Hermit Crab -- C. McGee For Adolescents with Mood Disorders When Nothing Matters Anymore: A Survival Guide for Depressed Teens -- B. Cobain Recovering from Depression: A Workbook for Teens -- M. E. Copeland & S. Copans Conquering the Beast Within: How I Fought Depression & Won…& How You Can, Too -- C. Irwin Everything You Need to Know about Bipolar Disorder & Manic Depressive Illness -- M. A. Summers Books for Clinicians Raising a Moody Child: How to Cope with Depression and Bipolar Disorder -- M.A. Fristad & J.S. Goldberg- Arnold New Hope for Children & Teens with Bipolar Disorder—B Birmaher A Parent's Survival Guide to Childhood Depression -- S. Dubuque The Ups and Downs of Raising a Bipolar Child --J. Lederman & C. Fink If Your Child is Bipolar – The Parent-to-Parent Guide to Living with and Loving a Bipolar Child -- C. Singer & S. Gurrentz Understanding Psychiatric Medications Straight Talk About Psychiatric Medications for Kids ---T. Wilens Understanding School Systems From Emotions to Advocacy–The Special Education Survival Guide--P & P Wright The Student with Bipolar Disorder, An Educator’s Guide --- T. Anglada

National Alliance for the Mentally Ill (NAMI)  1-800-950-6264 www.nami.org National Mental Health Association (NMHA)  1-703-684-7722 www.nmha.org Parenting Bipolars: A Survival Guide for Parents www.parentingbipolars.com

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