# Evidence-based assessment/Bipolar disorder in youth (assessment portfolio)/extended version

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Evidence-based assessment/Bipolar disorder in youth (assessment portfolio)/Sidebar

## What is a "portfolio?"

For background information on what assessment portfolios are, click the link in the heading above.
Does all of this feel like TMI? Click here to go to a condensed version.

## Preparation phase
### Diagnostic criteria for Pediatric Bipolar disorder

   ICD-10 Criteria
   F31 Bipolar affective disorder
   * Note. Episodes are demarcated by a switch to an episode of opposite or mixed polarity or by a remission.
   F31.0 Bipolar affective disorder, current episode hypomanic
   A. The current episode meets the criteria for Hypomania F30.0:
   * (A) The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least four consecutive days.
   * (B) At least three of the following signs must be present, leading to some interference with personal functioning in daily living
   ** Increased activity or physical restlessness;
   ** Increased talkativeness;
   ** Distractibility or difficulty in concentration;
   ** Decreased need for sleep;
   ** Increased sexual energy;
   ** Mild over-spending, or other types of reckless or irresponsible behavior;
   ** Increased sociability or over-familiarity.
   * (C) The episode does not meet the criteria for F30.1 Mania without psychotic symptoms, F30.2 Mania with psychotic symptoms, F31.- Bipolar affective disorder, F32.- Depressive episode, F34.0 Cyclothymia, or F50.0 Anorexia nervosa.
   * (D) Most commonly used exclusion clause. The episode is not attributable to F10-F19 Psychoactive substance use or in the sense of any F00-F09 Organic mental disorder.
   B. There has been at least one other affective episode in the past, meeting the criteria for F30.- Hypomanic or Manic episode, F32.Depressive episode, or F38.00 Mixed affective episode.
   Changes in DSM-5
   The diagnostic criteria for bipolar disorders changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

### Base rates of PBD in different clinical settings and populations

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rates of PBD that they are likely to see in their clinical practices.
* To find prevalence rates across multiple disorders, click here.
| Setting | Base Rate | Demography | Diagnostic Method | Best Recommended For |
| Community epidemiological (NCS-A) | 3.0% | All of U.S.A. | CIDI 3.0 | |
| Community epidemiologic samples | mean= 1.8% (95% CI, 1.1%–3.0%), bipolar I (mean =1.2%; 95% CI, 0.7%–1.9%) | U.S.A., Netherlands, U.K., Spain, Mexico, Ireland, New Zealand | Structured and semi-structured diagnostic interviews, Combination of broad and specific diagnostic criteria (Meta-Analysis) | Schools, nonclinical settings. Minimum for outpatient settings. |
| Community mental health center | 6% | U.S.A., Midwestern Urban, 80% non-white, low-income | Parent and youth clinical assessment & treatment | |
| General outpatient clinic | 6-8% | Urban academic research centers | WASH-U-KSADS (parent and youth) | |
| Specialty outpatient service | 15-17% | Boston area, U. S. A. | KSADS-E | |
| Inpatient Services/Diagnoses | 0.3% | All of Germany | International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) | |
| Community sample | 2.9% | Oregon | LIFE, SCID, DSM-IV | |
| Inpatient service | 30% manic symptoms, <2% strict BP I | New York City Metro Region | DICA; KSADS | |
| NCS-A Clinical Reappraisal Sample $^{py}$ | 6.2% and SE=1.7 (bipolar I and II and sub-threshold bipolar spectrum disorder) | U.S.A, NCS-A | K-SADS, DSM-IV criteria were modified from published version for purpose of the study, broad criteria for not otherwise specified | |
| NCS-A Clinical Reappraisal Sample $^p$ $^y$ | 6.6% and SE=1.7 (bipolar I and II and sub-threshold bipolar spectrum disorder) | U.S.A, NCS-A | CIDI, DSM-IV criteria were modified from published version for purpose of the study, broad criteria for not otherwise specified, | |
| National Cross‐sectional epidemiological sample $^p$ $^y$ | 1.2% (bipolar I and II and not otherwise specified) | United Kingdom | DAWBA, DSM-IV criteria, broad criteria for not otherwise specified | |
| Community epidemiological samples $^y$ | 2.5% (bipolar I and II) | Mexico City | CIDI, DSM-IV Criteria | |
| 2-stage epidemiological study $^{py}$ | 0.0% (bipolar I and II, cyclothymia, not otherwise specified | Ireland | K-SADS, DSM-IV Criteria | |
$^p$:Parent interviewed as component of diagnostic assessment; $^y$:Youth interviewed as part of diagnostic assessment.
Note:
* KSADS = Kiddie Schedule for Affective Disorders and Schizophrenia,
* WASH-U = Washington University version, -PL = Present and Lifetime Version, -E = Epidemiological version of the KSADS
* LIFE = Longitudinal Interval Follow-Up Evaluation,
* DICA = Diagnostic Interview for Children and Adolescents
* CIDI = Composite International Diagnostic Interview
* DAWBA= The Development and Well-Being Assessment

## Prediction phase

The following section contains a list of screening and diagnostic instruments for bipolar disorder in youth. This section includes administration information, psychometric data, and PDFs or links to the screenings.

### Psychometric properties of screening instruments for pediatric bipolar disorder

* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.
Screening measures for bipolar disorder in youth :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
| Children's Depression Inventory *not free | Self-report | 7-17 | 15-20 minutes | NA | A | G | G | X | Not free |
| Mood and Feelings Questionnaire (MFQ) | Self-report | 7-18 | 5-10 minutes | NA | A | G | A | X | MFQ Child Self-Report Long Version MFQ Child Self Report Short Version MFQ Parent Report On Child Long Version MFQ Parent Report On Child Short Version Assessment Center Online- long version Assessment Center Online- short version |
| 7 Up 7 Down Inventory (7U7D) | Self-report | 11-86 | 5-8 minutes | NA | | | | | 7U7D English Depression and Bipolar Support Alliance (DBSA): 7U7D Online Screener Assessment Center Online Version |
| Parent General Behavior-10 Item Version (PGBI-10M) | Parent-report | 5-18 | 5-8 minutes | | | | | | Downloadable PDF Parent-Report English Assessment Center Online Parent Version Assessment Center Online Child version |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening measures for bipolar disorder in youth

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
The following table describes the diagnostic likelihood ratios and area under curves for the top pediatric bipolar disorder measures.
| Screening Measure | AUC (sample size) | Very Low risk range DiLR | Low risk range DiLR | Neutral risk range DiLR | High risk range DiLR | Very High risk range DiLR | DLR+ (score) | DLR- (score) | Population/Clinical Generalizability | Download |
| Parent General Behavior-10 Item Mania Version (PGBI-10M) | .84 (N=617) academic sample, .78 community sample (N=530) | .07 (0 to 2.59) | .41 (2.6 to 6.99) | 1.44 (7 to 10.99) | 2.39 (11 to 17.99) | 5.38 (18+) | | | Bipolar spectrum vs. all other diagnoses | Parent Form |
| Parent General Behavior-10 Item Depression Version Form A (PGBI-10Da) | .84 (N=617) academic sample, .79 community sample (N=530) | .25 (0 to 1.99) | .71 (2 to 5.99) | 1.85 (6 to 9.99) | 4.52 (10 to 14.99) | 8.80 (15+) | | | Bipolar spectrum vs. all other diagnoses | |
| Parent General Behavior-10 Item Depression Version Form B (PGBI-10Db) | .84 (N=617) academic sample, .80 community sample (N=530) | .22 (0 to 1.99) | .71 (2 to 5.99) | 2.69 (6 to 10.99) | 5.64 (11 to 14.99) | 8.09 (15+) | | | Bipolar spectrum vs. all other diagnoses | |
| Parent General Behavior Inventory (P-GBI) (Hypomanic/Biphasic Section]) | .84 (N=324) | | (<9) | | | (49+) | 9.2 | .06 | Bipolar spectrum vs. all other diagnoses | |
| Parent Mood Disorder Questionnaire (P-MDQ) | .84 (N=819) | | (TBC) | | | (TBC) | 4.64 | .17 | Bipolar spectrum vs. all other diagnoses | MDQ |
| Child Mania Rating Scale (Brief) (Brief CMRS-P) | .85 (N=150) | | (<11) | | | (11+) | 10.5 | .17 | Bipolar spectrum vs. ADHD | |
| Child Mania Rating Scale (Full) (Full CMRS-P) | .91 (N=150) | | (<21) | | | (21+) | 13.7 | .19 | Bipolar spectrum vs. ADHD | Downloadable PDF |
| Child Bipolar Questionnaire (CBQ-P) | .74 (N=497) | | | | | | 25.3/ (likelihood ratio +) | /.25 (likelihood ratio -) | Bipolar spectrum vs. all other diagnoses | |

### Interpreting bipolar disorder screening measure scores

For information on interpreting screening measure scores, click here.

## Prescription phase
### Gold standard diagnostic interviews

For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

### Recommended diagnostic instruments specific for pediatric bipolar disorder

Diagnostic instruments for (insert portfolio name) :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
| Children's Depression Rating Scale - Revised (CDRS-R) | Structured Interview | 6-12 | 15-20 minutes | G | A | G | G | X | Link to purchase CDRS-R PDF (excerpt) |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

The following section contains a list of process and outcome measures for adolescent bipolar spectrum disorder. The section includes benchmarks based on published norms and on mood samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information on differences between process and outcome measures, see the page on the process phase of assessment.

### Process measures

There are many processes that may be considered important when evaluating a child or an adolescent with Bipolar Disorder; however, due to the diversity of the population and symptom expression, there are too many to narrow down. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility). The measures provided below are commonly used to assess and provide important information regarding levels of daily functioning of individuals with Bipolar Disorder.
   A. Mood and Energy Thermometer- This is an improved and practical way of monitoring complex mood cycles and daily schedules. Given that some clinicians and patients may get confused about different 1 to 10 scales (e.g., a 10 could mean extreme depression, extreme mania, or no depression), the Mood & Energy Thermometer improves the language in communicating (and monitoring) mood. Moreover, many children report their energy levels more accurately than their mood and therefore, energy levels have been incorporated in this mood rating. The Mood & Energy Thermometer that was developed at Western Psychiatric Institute and Clinic (WPIC; and used in about 400 kids) rates mania and increased energy on a 1 to 10 scale, rates depression and tiredness on a -1 to -10 scale, and attempts to form a common language between patients, families, and clinicians. This scale also takes into account time spent depressed and/or manic; for example, -4 would mean “mild depression” and “mild tiredness” present ≥50% of the time, and -3 would mean “mild depression” and “mild tiredness” present < 50% of the time. The inclusion of measuring energy levels is consistent with the DSM-5, because energy level is now included in the DSM-5 as a main mood symptom criterion. Bipolar track patients (whether they had mania, depression, or mixed features) rated their mood and energy levels every day on this scale, and a master’s-level clinician met with them on a daily basis to help them better identify and record their mood symptoms, which has significant clinical value for not only treatment but also to prevent future episodes.
   * Mood and Energy Thermometer
   * Mood and Energy Thermometer with Anger and Anxiety (with recording/monitoring card)
   * Mood and Energy Thermometer with Anger and Anxiety - Simplified Version
   B. Life Charts
   * To learn more about how life charts can be used with adolescent depression, see here
   * Life Charts for Depression and Bipolar

### Outcome and severity measures

* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF overall, see here.

#### Clinically significant change benchmarks with common instruments for bipolar disorder in youth

| | Cut Scores | Cut Scores | Cut Scores | Critical Change (Unstandardized Scores) | Critical Change (Unstandardized Scores) | Critical Change (Unstandardized Scores) | Minimally Important Difference |
| Measure | Away | Back | Closer | 95% | 90% | SEdifference | (MID) d ~.5 |
| PGBI-10M | 1 | 9 | 6 | 6 | 5 | 3.2 | 3 |
| CMRS 10 | -- | 6 | 4 | 5 | 4 | 2.3 | 2 |
| PGBI-10Da | -- | 7 | 4 | 6 | 5 | 3.0 | 3 |
| PGBI-10Db | -- | 7 | 4 | 6 | 5 | 2.9 | 3 |
| AGBI-10M | -- | 14 | 7 | 6 | 5 | 3.1 | 3 |
| AGBI-10Da | -- | 18 | 7 | 6 | 5 | 3.2 | 3 |
| AGBI-10Db | -- | 16 | 7 | 6 | 5 | 2.9 | 4 |
| 7 Up | -- | 8 | 4 | 4 | 4 | 2.2 | 3 |
| 7 Down | -- | 12 | 5 | 5 | 4 | 2.3 | 3 |
| KMRS | 19 | 19 | 19 | 3 | 3 | 1.6 | 3 |
| KDRS | 12 | 19 | 18 | 5 | 4 | 2.4 | 3 |
| CDRS-R Total | -- | 24 | 22 | 6 | 5 | 2.9 | 5 |
| YMRS Total | 4 | 3 | 3 | 3 | 3 | 1.8 | 3 |
Benchmarks Based on Published Norms :
| Measure | Subscale | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Measure | Subscale | A | B | C | 95% | 90% | SE$_{difference}$ |
| Beck Depression Inventory | BDI Mixed Depression | 4 | 22 | 15 | 9 | 8 | 4.8 |

### Treatment
#### Psychotherapy

Psychotherapies are treatments that help people with a wide variety of mental health concerns. While different forms of psychotherapies for adolescent bipolar disorder aim to remedy different aspects of the disorder, all aim to alleviate symptoms and decrease functional impairment in the client.
Overview of Psychotherapies :
| Therapy | Key components | Duration | Results |
| Child- and Family-Focused Cognitive-Behavioral Therapy | Develop consistent routines Learn to regulate emotions Improve child's self-esteem and parent's self efficacy Reduce negativity Build social skills and networks Teach parents self-care Family-based problem solving and communication skill building | 12 weeks long 60-90 minute weekly sessions | Decrease intensity of manic episodes Decrease depressive symptoms in child Overall improvement in client's functioning |
| Interpersonal and Social Rhythm Therapy | Develop understanding of disruptions in routine and manic/depressive episodes Build skills for creating consistent routines, aka, social rhythms Build self-efficacy and phase out of therapy | Varies dependent on client need | Increases time between manic/depressive episodes |
| Mindfulness-Based Cognitive Therapy | Utilizes mindfulness-based practices such as mindfulness meditation Focus on awareness of client's thoughts, feelings and behaviors Learn to recognize how to monitor one's own thoughts Increase self-care practices | 8 weeks long 60-120 minute weekly sessions | Decrease in anxiety symptoms Decrease in depressive symptoms Increase mood regulation Increase attention ability |
| Multi-Family Psychoeducational Psychotherapy | Group therapy using treatment components from: Psychoeducation Family Systems therapy Cognitive-behavioral therapy | 8 weeks long 60-90 minute weekly sessions | Decrease in severity of mood symptoms Increase in caregiver understanding of child's disorder and how to seek mental health care Children report feeling more social support from caregivers |

##### Child- and Family-Focused Cognitive-Behavioral Family (CFF-CBT)
###### Purpose

CFF-CBT was created to address the unique needs of bipolar disorder in children and adolescents with bipolar disorder, including rapid cycling, mixed mood states and comorbid disorders. This treatment has been tested to see if it will help address the high suicide attempt rate among children/adolescents with the disorder, and no significant effects were found. However CFF-CBT has been found to be effective for 7-13 year olds with both clients with and without non-suicidal self-injury behaviors. Mediators of this intervention include: parenting skills and coping, family flexibility, and family positive reframing.

###### Intended Population

Children aged 7-13 and adolescents aged 13-17

###### Length of Treatment

12 weekly sessions, with session time ranging from 60 to 90 minutes

###### Treatment Components

CFF-CBT focuses on 7 components comprising of the “RAINBOW” acronym:
R: Routine; developing consistency
A: Affective regulation; includes psychoeducation on feelings, coping skills, and mood monitoring
I: “I can do it!”; this aims to improve self-esteem in the child, as well as self-efficacy in the parent
N: “No Negative Thoughts/Live in the Now”
B: Be a good friend/balanced life style (building social skills and teaching parents self-care
O: Oh, how do we solve this problem? (family-based problem solving and communication skills building)
W: Ways to find support (building a network of support)

###### Treatment Outcomes

CFF-CBT has shown decreases in mania to a subclinical level, parent-reported youth depressive symptoms, increased involvement/fidelity to treatment, and improvements in the client’s overall, global functioning in comparison to psychotherapy as per usual.

##### Interpersonal and Social Rhythm Therapy (IPSRT)
###### Purpose

IPSRT is based on the social zeitgeber hypothesis, which states that regularity in social routines and interpersonal relationships acts as a protective factor for mood disorders. Thus, this treatment focused on maintaining regularity in daily routines, quality of social relationships and social roles, and management of consequences of rhythm disruptions.

###### Intended Population

IPSRT is intended for all individuals with bipolar disorder, and has been found to be effective in adolescents.

###### Length of Treatment

Length of treatment varies dependent on client needs.

###### Treatment Components

IPSRT is structured in three phases:
* Initial phase: Explores the clients history in order to explore links between disruptions in routines to affective episodes. This stage also includes education on the rationale of the treatment
* Intermediate phase: Focused on reorganizing the client's social rhythms, reinforcing new social rhythms and building confidence in using techniques that are taught in the treatment
* Final phase: Reduction in frequency of visits in order to work towards termination of therapy and self-efficacy

###### Treatment Outcomes

If applied early in the acute phase of bipolar disorder, IPSRT may prolong time to relapse in depressive/manic episodes.

##### Mindfulness-Based Cognitive Therapy (MBCT)
###### Purpose

Mindfulness approaches aim to enhance one’s ability to focus their attention on the present moment in a non-judgmental manor. In treatment for Bipolar Disorder, mindfulness approaches may focus on awareness of the client’s patterns of thoughts, feelings and bodily sensations both specific and non-specific to their experiences related to the disorder. Moreover, when comorbid with anxiety, bipolar disorder has higher risk of suicide attempts, therefore MBCT aims to decrease these anxiety symptoms.

###### Intended Population

MBCT is intended for all populations with bipolar disorder.

###### Length of Treatment

MPCT is typically offered in 1-2 hour weekly sessions over an 8-week period in a group setting (Perich et al 2012; Weber et al 2010). Participants are also assigned homework, including varying lengths of meditation practice.

###### Treatment Components

MPCT combines aspects of classical CBT and mindfulness-based stress reduction therapies. The themes addressed in each session are:
Session 1: Automatic pilot
Session 2: Dealing with barriers
Session 3: Mindfulness of the breath
Session 4: Staying present
Session 5: Allowing and letting be
Session 6: Thoughts are not facts
Session 7: How can I best take care of myself
Session 8: Using what has been learned to deal with future moods

###### Treatment Outcomes

Treatment outcomes include decreases in anxiety and depressive symptoms and mood regulation in patients with bipolar disorder, but there has been no evidence in prevention of recurrences. MBCT has also been found to improve attentional readiness, and attenuated activation of non-relevant information processing during attentional readiness, which are usually decreased in individuals with Bipolar Disorder compared to those without.

##### Multi-Family Psychoeducational Psychotherapy (MF-PEP)
###### Purpose

MF-PEP is a group-based evidence based treatment for children with bipolar disorder, which is meant to increase the ability for the treatment to be readily implemented into the community. While MF-PEP creates a support system within the family for the child through being a family-based intervention, it also serves to increase social support for care givers through being a group-based therapy.

###### Intended Population

MF-PEP is intended for children with depressive and bipolar disorders and their caretakers.

###### Length of Treatment

MF-PEP is an 8-session long treatment, with sessions typically ranging from 60-90 minutes.

###### Treatment Components

MF-PEP combines psychoeducation, family systems, and cognitive behavior therapy techniques, aiming to target depressive and bipolar disorder symptoms and how these symptoms cause impairment. In MF-PEP, sessions are delivered in a combination of settings, including all children and parents together, as well as separating all children and caregivers into their own respective groups.

###### Treatment Outcomes

Treatment outcomes for MG-PEP include an increase in caregiver's understanding of the child's disorder, and a decrease in mood symptom severity within the children which has been seen to be maintained through an 18-month follow-up. Additionally, MF-PEP has been found to have a positive effect on parent's help-seeking behaviors for mental health care, leading to access to higher-quality services. Lastly, children report feeling a stronger sense of social support from their caregivers after participating in the intervention.

##### See Also:

* Wikipedia has a page reviewing treatments for bipolar disorder.
* Effective Child Therapy provides a curated list of effective psycho-social treatments for bipolar disorder in youths.
* ICD-10 Diagnostic Criteria
* Bipolar disorder in children
* The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research
* Treatment of bipolar disorder

## External resources

* National Alliance on Mental Illness – the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. NAMI advocates for access to services, treatment, supports and research and is steadfast in its commitment to raise awareness and build a community for hope for all of those in need.
* Balanced Mind Foundation – information, articles, parent support chat rooms.
* Effective Child Therapy – Information and articles curated by Society of Clinical Child and Adolescent Psychology(SCCAP), a division of the American Psychological Association.
** Effective Child Therapy information: Bipolar Disorder
** Effective Child Therapy information: Severe Mood Swings and Bipolar Spectrum Disorders
** Effective Child Therapy information: Sadness, Hopelessness, and Depression
* International Bipolar Foundation – information, help and resources available for caregivers and those afflicted with bipolar disorder.
* Bipolar Network News – an online clearinghouse and information on latest treatments, research and psychoeducation about mood disorders.
* Depression Alliance – a United Kingdom charity that works to prevent and relieve depression by providing information and support services via supporter services, publications and self-help groups.
* Depression and Bipolar Support Alliance (DBSA) – a peer-directed national organization that provides links to resources, support groups, and peer support for individuals and their families suffering from bipolar disorder.
** Depression and Bipolar Support Alliance: 7 Up 7 Down Online Screener
* Related Wikipedia Pages
** Bipolar disorder Wikipedia Page
** Cyclothymia Wikipedia Page
** Mania Wikipedia Page
** Depression Wikipedia Page
* Massachusetts General Hospital School Psychiatry Resources for Bipolar Disorder
* The Psych Show with Dr. Ali Mattu videos
** How to Cope with Bipolar Disorder
** Top 10 Bipolar Myths
* Evidence Based Psychotherapies for Adolescent Bipolar Disorder