Examination of concordance between maternal and youth reports in the diagnosis of pediatric bipolar disorder.

Although the level of certainty in the assessment of psychopathology in the field of child and adolescent mental health is highest when both mother and child endorse a clinical diagnosis, unfortunately, this agreement does not always occur in clinical practice. In such cases, clinicians face the dilemma of how to handle discrepant maternal and child reports. The reasons for these discrepancies are not well understood. It is possible that children and adults have different thresholds for considering certain symptoms clinically significant, which would account for the discrepant rates reported by parents and youth (1). Of greater concern is the possibility that incongruent reports given by youth and mothers are the result of false positives cases reported by youth or mother. This issue is particularly troubling in the assessment of bipolar disorder in the young, in light of the ongoing controversy surrounding this diagnosis. Previous studies have provided insight into the meaning of discordant youth and parent reports of various disorders. For example, Braaten and colleagues (2) showed that youth self-reports of major depressive disorder in the absence of parental reports identified a mild form of depression associated with limited morbidity and disability. A study of concordance of attention-deficit hyperactivity disorder (ADHD) (3) indicated that maternal reports of ADHD were a meaningful diagnosis with high levels of impairment irrespective of the youth’s report of ADHD. The literature examining parental and youth reports in the diagnosis of bipolar disorder in youth is mixed. Tillman and colleagues (4) reported low levels of agreement between symptoms of mania reported by parents and children, and concluded that child reports were necessary for a comprehensive assessment of mania in the young. On the other hand, Kahana and colleagues (5) found that parental reports using the Child Behavior Checklist were better than youth self-reports at predicting a diagnosis of bipolar spectrum disorder. One could argue that the severity of the symptomatic picture of mania leads to a spectrum of aberrant behaviors that make the disorder evident to the family and thus identifiable to the parent. Furthermore, considering that mania is commonly associated with poor judgment, it is not entirely surprising that some afflicted youth may have limited insight into their disorders, irrespective of external evidence to the contrary. As stated above, it is also possible that children have higher thresholds for considering certain symptoms clinically significant, which would account for the discrepancies between parent and youth reports (1). Although discrepancies between child and mother reports could be bidirectional, since the mother is usually the initiator of the child’s referral, the most common dilemma in clinical practice is what to do when the child report is negative while the maternal report endorses a diagnosis. In such cases it is important for the clinician to have a sense of how informative maternal reports are in the absence of corroborating endorsement by the youth. Such knowledge has important implications for the clinician in how to proceed in the course of treatment with a youth suspected of suffering from bipolar disorder based on maternal reports. One approach to understanding this issue is to evaluate whether the clinical correlates of mania differ between concordant and discordant reports. If an informant provides a valid report of bipolar symptoms, then the resulting diagnosis should be associated with the serious clinical correlates characteristic of the disorder. Conversely, diagnoses based on spurious information should not demonstrate these associations. That is, if discordant reports are associated with the same clinical correlates and impairment, the diagnosis of mania should not be discounted. However, if the discordant cases are associated with higher functioning or have fewer clinical correlates compared to concordant cases, we can conclude that discordant reports may be false positives or represent a milder form of the disorder. The main aim of this study was to evaluate the informativeness of maternal reports of mania in discordant cases, i.e., cases in which the diagnosis of mania is not corroborated by the youth. To this end, comparisons were made between discordant and concordant reports of mania in a large sample of youth with bipolar I disorder to examine whether they differed by informant source in severity, onset, duration, and treatment of mania, symptom profiles, comorbidities, intellectual functioning, and family psychopathology. Differences in family psychopathology were compared between the groups to determine whether mothers from discordant families were more likely to endorse psychopathology in other children compared to concordant mothers or whether maternal psychopathology was associated with lack of concordance. In addition, we investigated the agreement of mother and child symptom reports and compared them to a previous study (4) to determine whether discordant reports may be due to differences in reports of specific symptoms. We hypothesized that concordant and discordant cases would not differ on these clinical features and correlates, supporting the validity of maternal diagnoses of mania when not corroborated by the youth.