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Psychometric Properties of the Young Mania Rating Scale for The Original Paper Psychopathology 2011;44:125–132 Received: October 15, 2009 DOI: 10.1159/000320893 Accepted after revision: September 2, 2010 Published online: January 12, 2011 Psychometric Properties of the Young Mania Rating Scale for the Identification of Mania Symptoms in Spanish Children and Adolescents with Attention Deficit/Hyperactivity Disorder a, b b a a Eduardo Serrano Lourdes Ezpeleta José A. Alda José L. Matalí a, c Luis San a Department of Child and Adolescent Psychiatry and Psychology, Hospital Sant Joan de Déu, and b Unitat d’Epidemiologia i de Diagnòstic en Psicopatologia del Desenvolupament, Universitat Autònoma de c Barcelona, and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona , Spain Key Words acteristic curve analysis showed good diagnostic efficiency Attention deficit/hyperactivity disorder ؒ Mania, detection ؒ in differentiating mania in ADHD (area under the curve of -Children and adolescents ؒ Young Mania Rating Scale 0.90). Conclusions: The Spanish version of the YMRS is a val id and reliable instrument for detecting and quantifying the symptoms of mania in children and adolescents with ADHD. Abstract The results provide further knowledge about the frequent Background: Diagnosing mania in children is difficult, due association between ADHD and manic symptoms in chil- to the high comorbidity and symptom overlap with atten- dren. Copyright © 2011 S. Karger AG, Basel tion deficit/hyperactivity disorder (ADHD). The detection of manic symptoms in ADHD has important implications for prognosis and choice of treatment. Our objective was to study the utility of the Young Mania Rating Scale (YMRS) for Introduction discriminating mania in Spanish children with ADHD. Meth- od: One hundred children and adolescents with ADHD be- In recent decades, it has been recognized that bipolar tween 8 and 17 years of age were evaluated with a structured disorder (BPD) could have onset at young ages [1–3] . diagnostic interview (Diagnostic Interview for Children and There is a consensus among researchers and clinicians Adolescents-IV), the YMRS, the Parent-Young Mania Rating about the difficulty of diagnosing pediatric mania. This Scale (P-YMRS), the Child Mania Rating Scale-Parent Version difficulty is primarily due to 3 factors: (1) the clinical pre- (CMRS-P) and the Children’s Global Assessment Scale. Re- sentation of mania in children, (2) the overlapping of sults: The YMRS showed a 1-dimensional structure with symptoms of mania with attention deficit/hyperactivity good internal consistency and test-retest reliability. The disorder (ADHD) and (3) its high comorbidity with YMRS was associated with the P-YMRS and the CMRS-P. The ADHD. scores obtained with the YMRS differentiated between The clinical presentation of BPD in prepubertal chil- ADHD with and without mania. The receiver operating char- dren and in early adolescence is a matter of debate and © 2011 S. Karger AG, Basel Eduardo Serrano 0254–4962/11/0442–0125$38.00/0 Department of Child and Adolescent Psychiatry and Psychology Fax +41 61 306 12 34 Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2 E-Mail [email protected] Accessible online at: ES–08950 Esplugues del Llobregat, Barcelona (Spain) www.karger.com www.karger.com/psp Tel. +34 93 280 40 00, ext. 4350, Fax +34 93 280 63 49, E-Mail eserrano @ hsjdbcn.org shows differences with respect to classic manic-depres- multidimensional and more complex than the classic eu- sive symptoms in adults. The symptoms of euphoria and phoric-dysphoric dichotomy [21] . inflated self-esteem, and the episodic course are rare in The difficulty in discriminating between BPD and children [4, 5] . Affective phenomenology is often mixed, ADHD leads to the diagnosis of false negatives (not rec- and dysphoria with ‘affective storms’ and severe out- ognizing BPD if there is ADHD) or false positives (diag- bursts of anger are much more frequent than euphoria. nosing BPD when only ADHD is present). The impor- The course is often chronic, discontinuous and erratic tance of differentiating symptoms of mania in children [6–8] . The National Institute for Mental Health research and adolescents with ADHD and making a proper diag- roundtable on prepubertal BPD [9] reached an agreement nosis is not only a nosological matter, but has significant that pediatric BPD can present as ‘narrow’ (fitting the implications for prognosis and choice of treatment [22– classic definition of BPD-I or BPD-II described in DSM- 24] . IV [10] ) or ‘broad’ (basically BPD not otherwise specified Therefore, it is essential to have specific instruments that includes children who do not meet DSM criteria but with strong psychometric properties to assess pediatric who are still severely impaired by symptoms of mood in- mania and enable the clinician to quantify the presence stability). Other authors have suggested a phenotypic sys- and severity of manic symptoms. We currently have few tem of juvenile mania consisting of a narrow phenotype, instruments that specifically assess juvenile mania. The 2 intermediate phenotypes and a broad phenotype, ac- most widely studied in BPD, and developed to be used on cording to the presence of distinct episodes and hallmark adults, is the Young Mania Rating Scale (YMRS) [25] . The symptoms [11] . YMRS is an 11-item scale designed to be completed by the Comorbidity studies show the frequent co-occurrence clinician. The scale assesses the intensity of manic symp- of ADHD and BPD. In a sample of young people with toms based on a clinical interview with the patient and ADHD, Biederman et al. [12] found that 23% had BPD, takes into account the subjective comments of the inter- which is similar to the 22% reported by Butler et al. [13] viewee and the clinician’s own observation. The instru- and the 20% found by Wozniak et al. [8] . In Europe, Di- ment has shown adequate psychometric properties in ler et al. [14] found in an outpatient sample (7–13 years of adult inpatients [25] . Subsequently, studies have been age) with ADHD that 8.2% also had BPD. conducted to validate its use with children and adoles- There is a considerable debate about the difference in cents, which have also shown satisfactory psychometric pediatric BPD prevalence between the USA and Europe. properties [26–28] . The scale used on prepubertal chil- Epidemiologic studies in clinical samples in Europe re- dren (6–12 years old) differentiated BPD from ADHD, ported a prevalence of mania ranging from 0% in the UK while the scores from hyperactivity-specific instruments [15] to 4% in Spain [16] . In US outpatient samples it rang- (for parents and teachers) did not differ between groups es from 5.9 to 19.6% [17–20] . These differences may be [26] . In a later study also conducted on prepubertal chil- explained by the variations in methodology (range of age dren, the YMRS showed adequate internal consistency considered, rating scale used, person interviewed), ICD- ( ␣ = 0.80) and convergent validity with another measure 10 and DSM-IV differences in diagnostic criteria for BPD of mania (r = 0.83; p ! 0.0001) [27] . Youngstrom et al. [28] (ICD-10 requires at least 2 episodes of significantly dis- reported a single-factor structure and good internal con- turbed mood and activity), clinician bias against BPD sistency ( ␣ = 0.91) in children and adolescents (5–17 years (preference to classify such clinical presentations as se- of age). vere ADHD, conduct, depressive and personality disor- Studies for validating the YMRS in children have fo- ders instead of BPD), an overdiagnosis of the disorder cused on the scale’s effectiveness in discriminating BPD in the USA and/or a true higher prevalence of pediatric from ADHD or another disorder. Until now, no study has BPD in the USA [16] . assessed the utility of the YMRS in discriminating mania Another aspect that makes diagnosis difficult is the in children with ADHD. We do not currently have any frequent overlap of BPD and ADHD symptoms (distract- validated scale for the Spanish population that specifi- ibility, high levels of motor activity, racing thoughts, rap- cally assesses pediatric mania. The objective of this study id or accelerated speech, impulsivity, aggression and ir- is to analyze the reliability and validity of the Spanish ver- ritability) [12] . Despite considerable symptom overlap, sion of the YMRS for children and adolescents with mania can be distinguished from ADHD by the presence ADHD and thus evaluate the utility of the scale to detect of core symptoms of mania such as euphoria and grandi- and quantify symptoms of mania in ADHD. osity [17] . Nonetheless, the structure of mania may be 126 Psychopathology 2011;44:125–132 Serrano /Ezpeleta /Alda /Matalí /San Table 1. Sample description and comparison of scores on mania and functioning scales Total A DHD with mania (n = 14) ADHD p (n = 100) without mania BPD (DSM) BPD-NOS BPSD (n = 86) (n = 8) (n = 6) (n = 14) Median age, years 11 13.50 12 13 11 0.082 (range = 8–17) (range = 8–17) (range = 8–17) (range = 8–17) (range = 8–17) Sex Boys 84 (84) 7 (87.5) 6 (100) 13 (92.9) 71 (82.6) 0.458* Girls 16 (16) 1 (12.5) 0 1 (7.1) 15 (17.4) ADHD type Combined 75 (75) 7 (87.5) 5 (83.3) 12 (85.7) 63 (73.3) 0.508* Hyperactivity 9 (9) 0 1 (16.7) 1 (7.1) 8 (9.3) 1* Inattentive 16 (16) 1 (12.5) 0 1 (7.1) 15 (17.4) 0.458* Comorbidity Defiant disorder 71 (71) 8 (100) 6 (100) 14 (100) 57 (63.3) 0.001* Conduct disorder 15 (15) 4 (50) 5 (83.3) 9 (64.3) 6 (7) 0.001* CMRS-P 15 [0–53] 26 [3–53] 16.50 [10–31] 17 [3–53] 14 [0–43] 0.045 P-YMRS 12 [0–52] 18 [6–52] 17.50 [10–25] 18 [6–52] 11 [0–32] 0.017 YMRS 3 [0–33] 15 [3–33] 6.50 [5–27] 12 [3–33] 3 [0–16] 0.001 CGAS 55 [21–70] 40 [21–50] 50 [30–60] 41 [21–60] 59 [40–70] 0.001 Fig ures are numbers of cases with percentages in parentheses or medians with ranges in square brackets unless otherwise indi- cated.
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