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Evidence-Based Assessment Strategies for Pediatric Bipolar Disorder

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Evidence-Based Assessment Strategies for Pediatric Bipolar Disorder Isr J Psychiatry Relat Sci - Vol. 49 - No 1 (2012) ERIC A. YOUNGSTROM ET AL. Evidence-Based Assessment Strategies for Pediatric Bipolar Disorder Eric A. Youngstrom, PhD,1 Melissa McKeown Jenkins, MA, 1 Amanda Jensen-Doss, PhD, 2 and Jennifer Kogos Youngstrom, PhD1 1 Department of Psychology, University of North Carolina at Chapel Hill, North Carolina, U.S.A. 2 Department of Psychology, University of Miami, Miami, Florida, U.S.A. a result, practitioners have had minimal training in the assessment of PBD. Should busy clinicians invest the ABSTRACT time and effort to learn about evidence-based assess- Evidence-based assessment of pediatric bipolar ment strategies for pediatric bipolar disorder? Given the disorder has advanced rapidly in the last two decades, stakes involved in making this diagnosis correctly, as moving from isolated clinical case descriptions to what well as the rapid advances in the evidence base over the is now a portfolio of techniques that include checklists last several years, there are few niches that could provide from multiple informants, semi-structured diagnostic so substantial a return on investment. Other papers in interviews and severity ratings, and technologies this special issue review the distinction between PBD that allow daily tracking of mood and energy over the and other forms of mood dysregulation and aggression course of treatment. This review critically appraises (1, 2) and the evidence for the validity of PBD as distinct (a) the need for evidence-based assessment of bipolar from ADHD, depression, or other more common devel- disorder as a common component of clinical practice, opmental psychopathology (3). This review will address (b) triggers that warrant assessment of bipolar, (c) key topics, such as why to assess for PBD, when it is clini- when best to deploy different techniques over the cally indicated, how to change assessment strategies to course of diagnosis and treatment, and (d) promising match the individual needs of the patient over the course new developments in assessment. A decision-making of treatment, and what promising future directions might framework is adapted from evidence-based medicine be worth adding to clinical practices in the future. to guide assessment sequences in a patient-centered approach. Emphasis is placed on approaches that WHY ADD FORMAL assESSMENT PROCEDURES currently have the best validity and are feasible in most FOR PBD TO THE CLINIcaL TOOLBOX? clinical practice settings. These methods increase The place where PBD seems most scarce is in textbooks. accuracy and address many controversies surrounding There are now several thousand peer reviewed articles pediatric bipolar diagnoses. describing and validating pediatric bipolar disorder, drawn from dozens of independent research groups around the world (4). A recent meta-analysis of epide- miological studies found that ~2% of children and ado- Conventional wisdom was that bipolar disorder most lescents in the community - not clinics - meet criteria often manifested during young adulthood. Although for bipolar spectrum diagnoses (5), with equal rates in there were occasional case reports in childhood or early the U.S.A. versus the rest of the world. A Canadian study adolescence, pediatric bipolar disorder (PBD) was con- published after the meta-analysis replicated the 2% figure sidered exotic, and it was not part of the core training for (6). Increased rates of clinical diagnoses started from a physicians or mental health professionals working with baseline of almost never diagnosing PBD (7), and clinical youths. Even now, most textbooks and training materi- and epidemiological rates are now converging. als focus on bipolar disorder as an “adult” condition. As Where have these bipolar cases been hiding? Often in Address for Correspondence: Eric Youngstrom, Department of Psychology, University of North Carolina, CB #3270, Davie Hall, Chapel Hill, NC 27599-3270, U.S.A. [email protected] 15 EVIDENCE-BASED ASSESSMENT STRATEGIES FOR PEDIATRIC BIPOLAR DISORDER plain sight. Both community (8, 9) and clinical studies Index of Suspicion” (28, 29). Figure 1 illustrates how diag- (10-14) indicate that PBD is highly impairing. However, nostic probability maps onto clinical actions. EBM refers when families seek services, PBD often is missed. If the to two major choice points along this continuum: The mood symptoms are prominent, then the most likely Wait-Test Threshold, and the Test-Treatment Threshold diagnosis is major depression, contributing to the finding (27). Below the Wait-Test Threshold, a diagnosis is con- that one third of all cases with depression prove to have a sidered “ruled out.” Above the Test-Treatment Threshold, bipolar spectrum disorder when followed longitudinally a diagnosis is considered firm enough to begin treatment. (15, 16). If the energy and attention problems are salient, Between the two thresholds is where additional assess- then the likely diagnosis is ADHD or ODD, particu- ment is needed to either push the probability below the larly in Europe and Israel, whereas aggression is more Wait-Test or above the Test-Treatment Threshold. EBM likely to attract a conduct disorder label, and psychosis a does not attach specific numbers to these thresholds. schizophrenia diagnosis – especially in ethnic minorities Where to set the bar is a clinical judgment, depending in the U.S.A (17). Because bipolar is an episodic illness, on risks and benefits. Formal approaches for integrating with dramatically different presentations during differ- these utilities into decision-making may gain popularity ent phases, it is exceptionally challenging for clinicians to as technology reduces the inconvenience associated with develop a good prototype for the “typical” case. Prototype computation (27, 30). Table 1 lists steps in evidence-based matching is a main way that experienced clinicians for- assessment of PBD detailed below. mulate cases (18), but it performs badly with PBD (19, 20). Vignette studies demonstrate tremendous range of AN EVIDENCe-BasED PROCESS FOR THE DIAGNOSIS OF PBD opinion, often varying by global region, when clinicians • Step 1. Know the base rate of PBD in your setting. examine cases with potential PBD (21, 22). Clinical PBD The first piece of evidence to incorporate in fast, frugal diagnoses rarely agree with each other or with structured PBD assessment is its base rate in a clinical setting. interview results at better than chance rates (23), con- PBD rates vary widely depending on where one works. tributing to the long lag between onset of problems and PBD is rare in the general community, but somewhat diagnosis in youths (24) and adults (25, 26). more common in outpatient practices, and even more Diagnostic disagreement is less surprising considering in practices that specialize in mood disorders. Table the dearth of formal training about PBD, forcing prac- 2 lists benchmarks from different settings. In many titioners to learn as they work. Using evidence-based settings, PBD rates will fall below the clinician’s Wait- assessment tools can help close the gap, especially if Test threshold. For example, if a clinician decides that practitioners can easily incorporate the methods without conditions seen in fewer than 1 in 20 cases do not additional time, expense or training. PBD assessment has warrant extra assessment unless other warning signs evolved rapidly, with dozens of tests now having pub- are evident, then their Wait-Test threshold is 5%. If lished validity data. The challenges now are choosing the working where <5% of cases might have PBD, then best from among contenders, and understanding each they do not need to include PBD assessment measures tool’s role at different stages of assessment and treatment. as part of their standard intake procedure. When the target is already rare, low scores on the test will not WHEN IS ASSESSMENT OF PBD CLINIcaLLY INDIcatED? add information, and high scores will still usually be Evidence-based medicine (EBM) uses probability of false positives. On the other hand, if working where diagnosis as a way of organizing clinical decisions about PBD might be more common - such as an inpatient assessment and treatment (27). Every case has a possibility unit - assessment methods can quickly move some of having PBD, albeit often low. Test scores, risk factors, cases below the Wait-Test threshold, and others closer and other pieces of evidence refine our estimates of the to the Treatment zone. probability. When the probability is sufficiently low, the • Step 2. Assess PBD risk factors. There are risk factors diagnosis can be “ruled out,” at least until new information and cues that should trigger further assessment. Most triggers re-evaluation (see Figure 1). When enough con- well-established is a family history of bipolar disorder firmatory evidence accumulates, then the probability rises (31, 32) (see Table 3). Bipolar in a first degree rela- enough that we make the diagnosis and concentrate on tive is linked with at least a five-fold increase in risk organizing the treatment around it. This Bayesian frame- for PBD, and second-degree relatives with at least work is similar to clinical thinking such as the “Bipolarity half as much risk (33). Other warning signs for PBD 16 EVIDENCE-BASED ASSESSMENT OF BIPOLAR 28 EVIDENCE-BASEDEVIDENCE-BASED ASSESSMENT ASSESSMENT OF BIPOLAR OF BIPOLAR28 28 Assessment: Figure 1. Integrated Model of Evidenced-Based Assessment for Pediatric Bipolar Assessment:Assessment:Steps 7, 8, 9, 10. Assess Figure 1. 100% Steps 7, 8, Steps9, 10. 7,Assess 8, 9,factors 10. Assess that might change Integrated Model of Evidenced-Based Assessment for Pediatric Bipolar High treatment effectiveness. Figure 1. Figure 1. 100% 100% factors thatfactors might changethat might change Integrated ModelIntegrated of Evidenced-Based Model of Evidenced-Based Assessment Assessmentfor Pediatric for Bipolar Pediatric Bipolar High High Probability/treatment effectiveness.treatment effectiveness.Monitor process & adherence. Probability/Probability/Mania,Monitor processMonitor & adherence.processMeasure & adherence. “midterm” for Mixed,Measure Bipolar “midterm”Measure for“midterm” treatment for adjustment and Mania, Mania, outcomes.
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