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

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.

Diagnostic criteria for Pediatric Bipolar disorder

 * Pediatric bipolar disorder (PBD) is characterized by extreme fluctuations in mood or emotional dysregulation that range from mania (as shown by displays or feelings of extreme happiness, unrealistic overachievement, and anger) to depression (as shown by displays or feelings of sadness, changes in appetite or weight, and irritability ).
 * It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities. These mood fluctuations result in a child finding it difficult to live and interact with family, friends and teachers, when it was previously not an issue.
 * People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes". An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression.
 * People with bipolar disorder also may be explosive and irritable during a mood episode.
 * Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood.
 * It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania.
 * A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. These debilitating symptoms can result in an afflicted individual being unable to function adaptively in several settings.

 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. p:Parent interviewed as component of diagnostic assessment; y:Youth interviewed as part of diagnostic assessment.
 * To find prevalence rates across multiple disorders, click here.

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.

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Brief screening tools for PBD
The following are brief screening tools that typically take less than 5 minutes to administer to accurately diagnose pediatric bipolar disorder:


 * 1) 7 Up 7 Down Inventory (7U7D)
 * 2) The 7 Up 7 Down Inventory is a recently developed and validated questionnaire with 14 items of manic and depressive tendencies carved from the General Behavior Inventory, a well-validated but cumbersome interview. For both mania and depression factors, 7 items produced a psychometrically adequate measure applicable across both aggregate samples. Internal reliability of the Mania scale was .81 (youth) and .83 (adult) and for Depression was .93 (youth) and .95 (adult).
 * 3) The 7 Up 7 Down Inventory, along with the accompanying research article, can be found here.


 * 1) PGBI-10M
 * 2) The PGBI-10M (we would like to add another version that is better) is a brief (10 item) instrument derived from the Parent General Behavior Inventory (PGBI), a 73-item mood inventory, to assess mania in a large sample of outpatients presenting with a variety of different DSM-IV diagnoses, including frequent comorbid conditions.
 * 3) The 10-item GBI derived from the 73-item P-GBI had good reliability (alpha = .92), was correlated (r = 0.95) with the 28-item scale, and showed significantly better discrimination of bipolar disorders (area under the receiver operating characteristic [AUROC] curve of 0.856 vs. 0.832 for the 28-item scale, p < .005). The 10-item scale also did well discriminating bipolar disorder from unipolar depression (AUROC = 0.86) and bipolar disorder from attention-deficit/hyperactivity disorder (AUROC = 0.82) cases.
 * 4) The full version of the scale, the Parent-General Behavior Inventory (P-GBI), is a parent-report measure of depressive and hypomanic/biphasic symptoms adapted from the General Behavior Inventory (GBI).
 * 5) Classification rates exceed 80%, and receiver operating characteristic analyses showed good diagnostic efficiency for the scales, with areas under the curve greater than .80. Results indicate that clinicians can use the parent-completed GBI to derive clinically meaningful information about mood disorders in youths.

Likelihood ratios and AUCs of screening measures for bipolar disorder in youth
The following table describes the diagnostic likelihood ratios and area under curves for the top pediatric bipolar disorder measures.
 * For a list of the likelihood ratios for more broadly reaching screening instruments, click here.

Interpreting bipolar disorder screening measure scores
For information on interpreting screening measure scores, click here.

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


 * 1) Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (KSADS-PL)
 * 2) * The KSADS-PL is a semi-structured diagnostic interview that assesses current and past Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV-TR) Axis I psychopathology in youth . The KSADS-PL diagnostic interviews have good inter-rater (.93 to 1.00) and retest reliability (.77) for mood disorders Here is a link to a PDF of the diagnostic interview for the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime.
 * 3) Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)
 * 4) * The Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia(WASH-U-KSADS) was expanded from the 1986 version of the KSADS, which was modified and expanded to include onset and offset of each symptom for both current and lifetime episodes, expanded prepubertal mania and rapid cycling sections, and categories for attention deficit hyperactivity disorder and other DSM-IV diagnoses. To optimize diagnostic research, skip-outs were minimized.
 * 5) * The kappa values of comparisons between research nurse and off-site blind best-estimate ratings of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability for mania diagnoses (85.7%) and for individual mania items and validity against parental and teacher reports were previously reported.
 * 6) * The link to the diagnostic interview for the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia can be found here.

Recommended diagnostic instruments specific for pediatric bipolar disorder
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.

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.

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.

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 :


 * 1) 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
 * 2) 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
 * 3) 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.

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.

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

 * 1) 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.
 * 2) Balanced Mind Foundation – information, articles, parent support chat rooms.
 * 3) Effective Child Therapy – Information and articles curated by Society of Clinical Child and Adolescent Psychology(SCCAP), a division of the American Psychological Association.
 * 4) Effective Child Therapy information: Bipolar Disorder
 * 5) Effective Child Therapy information: Severe Mood Swings and Bipolar Spectrum Disorders
 * 6) Effective Child Therapy information: Sadness, Hopelessness, and Depression


 * 1) International Bipolar Foundation – information, help and resources available for caregivers and those afflicted with bipolar disorder.
 * 2) Bipolar Network News – an online clearinghouse and information on latest treatments, research and psychoeducation about mood disorders.
 * 3) 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.
 * 4) 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.
 * 5) Depression and Bipolar Support Alliance: 7 Up 7 Down Online Screener
 * 6) Related Wikipedia Pages
 * 7) Bipolar disorder Wikipedia Page
 * 8) Cyclothymia Wikipedia Page
 * 9) Mania Wikipedia Page
 * 10) Depression Wikipedia Page
 * 11) Massachusetts General Hospital School Psychiatry Resources for Bipolar Disorder
 * 12) The Psych Show with Dr. Ali Mattu videos
 * 13) How to Cope with Bipolar Disorder
 * 14) Top 10 Bipolar Myths
 * 15) Evidence Based Psychotherapies for Adolescent Bipolar Disorder