Diagnostic accuracy of Achenbach scales in detecting youths' substance use disorders.

It is vital to identify substance use disorders (SUDs) in youths and adults early and accurately. Previous studies have investigated the validity and reliability of the Achenbach Child Behavior Checklist (CBCL) and Youth Self Report (YSR) for other related anxiety, mood, and behavior problems. The present study tested if the CBCL and YSR substance use items can discriminate adolescents with versus without a SUD diagnosis accurately enough to justify clinical application within an evidence-based assessment framework. N = 422 outpatient adolescents (age 9-18) and their caregivers completed semistructured diagnostic interviews. Caregivers completed CBCL, and adolescents completed the YSR. K-SADS-PL + diagnoses indicated that 34 youths met Diagnostic and Statistical Manual (DSM)-IV criteria for SUDs. Receiver Operating Characteristics (ROC) models estimated the likelihood of having Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (KSADS-PL) + SUDs based on substance use scores of CBCL or YSR. Scores on all scales significantly identified KSADS-PL-diagnosed SUDs in adolescents: Area under the curve (AUCCBCL = .90, p < .0005; AUCYSR = .84, p < .0005). There was no significant difference in the accuracy comparing each informant used separately; CBCL showed incremental value above the YSR report when both were included in logistic regression models. CBCL and YSR substance items demonstrated diagnostic and clinical utility in identifying SUDs in adolescents. Findings suggest that Achenbach Scales could be a valuable intake instrument in detecting adolescents SUDs. A supplemental clinical vignette illustrates the clinical application of the study findings. It will be important for future research to replicate use of these measures across varying clinical scenarios and settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Evaluating and Validating GBI Mania and Depression Short Forms for Self-Report of Mood Symptoms.

Objective: To evaluate short forms of free self-report mania and depression scales, evaluating their reliability, content coverage, criterion validity, and diagnostic accuracy.Method: Youths age 11 to 18 years seeking outpatient mental health services at either an Academic medical clinic (N = 427) or urban Community mental health center (N = 313), completed the General Behavior Inventory (GBI) and other rating scales. Youths and caregivers completed semi-structured interviews to establish diagnoses and mood symptom severity, with GBI scores masked during diagnosis. Ten- and seven-item short forms, psychometric projections, and observed performance were tested first in the Academic sample and then externally cross-validated in the Community sample.Results: All short forms maintained high reliability (all alphas >.80 across both samples), high correlations with the full-length scales (r.85 to.96), excellent convergent and discriminant validity with mood, behavior, and demographic criteria, and diagnostic accuracy undiminished compared to using the full-length scales. Ten-item scales showed advantages in terms of coverage; the 7 Up showed slightly weaker performance.Conclusions: Present analyses evaluated and externally cross-validated short forms that maintain high reliability and content coverage, and show strong criterion validity and diagnostic accuracy - even when used in an independent sample with very different demographics and referral patterns. The short forms appear useful in clinical applications including initial evaluation, as well as in research settings where they offer an inexpensive quantitative score. Short forms are available in more than two dozen languages. Future work should further evaluate sensitivity to treatment effects and cultural invariance.

Developing and Validating Short Forms of the Parent General Behavior Inventory Mania and Depression Scales for Rating Youth Mood Symptoms.

To develop short forms of parent-rated mania and depression scales, evaluating their reliability, content coverage, criterion validity, and diagnostic accuracy. Caregivers completed the Parent General Behavior Inventory about their youth 5-18 years of age seeking outpatient mental health services at either an academic medical clinic (n = 617) or urban community mental health center (n = 530), along with other rating scales. Families also completed a semistructured Kiddie Schedule for Affective Disorders and Schizophrenia interview, with the rating scales masked during diagnosis. Ten-item short forms and projections of their psychometrics (vs. the full-length 46-item Depression and 28-item Hypomanic/Biphasic scales) were built in the academic sample and then externally cross-validated in the community sample. The mania and two depression short forms maintained high reliability (αs > .87 across both samples); high correlations with the full-length scales (rs> .93); excellent convergent and discriminant validity with mood, behavior, and demographic criteria; and diagnostic accuracy undiminished compared to using the full-length scales. Present analyses developed and externally cross-validated 10-item short forms that maintain high reliability and content coverage and show strong criterion validity and diagnostic accuracy-even when used in an independent sample with markedly different demographics and referral patterns. The short forms appear useful in clinical applications, including screening and initial evaluation, as well as in research settings, where they offer an inexpensive quantitative score. Future work should further evaluate sensitivity to treatment effects. The short forms are available in more than a dozen translations.

Positive Emotion Specificity and Mood Symptoms in an Adolescent Outpatient Sample.

Research on positive emotion disturbance has gained increasing attention, yet it is not clear which specific positive emotions are affected by mood symptoms, particularly during the critical period of adolescence. This is especially pertinent for identifying potential endophenotypic markers associated with mood disorder onset and course. The present study examined self-reported discrete positive and negative emotions in association with clinician-rated manic and depressive mood symptoms in a clinically and demographically diverse group of 401 outpatient adolescents between 11-18 years of age. Results indicated that higher self reported joy and contempt were associated with increased symptoms of mania, after controlling for symptoms of depression. Low levels of joy and high sadness uniquely predicted symptoms of depression, after controlling for symptoms of mania. Results were independent of age, ethnicity, gender and bipolar diagnosis. These findings extend work on specific emotions implicated in mood pathology in adulthood, and provide insights into associations between emotions associated with goal driven behavior with manic and depressive mood symptom severity in adolescence. In particular, joy was the only emotion associated with both depressive and manic symptoms across adolescent psychopathology, highlighting the importance of understanding positive emotion disturbance during adolescent development.

Comparing the Diagnostic Accuracy of Five Instruments for Detecting Posttraumatic Stress Disorder in Youth.

The purpose of the study was to compare diagnostic accuracy of five posttraumatic stress disorder (PTSD) measures in a large outpatient sample of youths 11-18 years of age. Index tests included a parent report (a rationally derived scale from the Child Behavioral Checklist), a teacher report (the Teacher Report Form), and three youth reports-a PTSD scale from the Youth Self Report (YSR), Child PTSD Symptom Scale, and Child and Adolescent Trauma Survey. Interviews with the youth and caregiver using Schedule for Affective Disorders and Schizophrenia for School-Age Children generated criterion diagnoses of PTSD. Diagnoses were blind to scores on the index tests. Based on consensus diagnoses (N = 458), 10% of youth had PTSD. Area under the curve (AUC) from receiver operating characteristic analyses and multilevel likelihood ratios evaluated test performance. All youth reports (AUCs .67-.73) outperformed the teacher report (AUCs .42-.48) at identifying PTSD. The YSR outperformed the caregiver reports (AUCs .57-.58). Combining tests did not improve prediction of PTSD. The YSR predicted PTSD even after controlling for a self-reported traumatic event, but checklist ratings of traumatic events had no incremental value after controlling for YSR scores. When a youth endorsed few symptoms, the likelihood of the youth having PTSD was low. Very high scores on the YSR were associated with a moderate increase in the likelihood of PTSD diagnosis. The YSR appeared to be a useful diagnostic aid for youth PTSD and could facilitate differential diagnosis of youth PTSD in outpatient settings.

Impact of Irritability and Impulsive Aggressive Behavior on Impairment and Social Functioning in Youth with Cyclothymic Disorder.

OBJECTIVE: Research on adults with cyclothymic disorder (CycD) suggests that irritability and impulsive aggression (IA) are highly prevalent among this population. Less is known about whether these behaviors might also distinguish youth with CycD from youth without CycD. Additionally, little is known about how irritability and IA relate to one another, and whether they are associated with different outcomes. This study aimed to compare irritability and IA across diagnostic subtypes to determine whether CycD is uniquely associated with these behaviors, and to assess how irritability and IA relate to youth social and general functioning. METHODS: Participants (n = 459), 11-18 years of age, were recruited from an urban community mental health center and an academic outpatient clinic; 25 had a diagnosis of CycD. Youth and caregivers completed measures of IA and irritability. Youth and caregivers also completed an assessment of youth friendship quality. Clinical interviewers assessed youth social, family, and school functioning. RESULTS: Youth with CycD had higher scores on measures of irritability and IA than youth with nonbipolar disorders, but scores were not different from other youth with bipolar spectrum disorders. Measures of irritability and IA were correlated, but represented distinct constructs. Regression analyses indicated that irritability was related to friendship quality (p < 0.005). Both IA and irritability were related to social impairment (ps < 0.05-0.0005) and Child Global Assessment Scale (C-GAS) scores (ps = 0.05-0.005). CycD diagnosis was associated with poorer caregiver-rated friendship quality and social functioning (ps < 0.05). CONCLUSIONS: We found that irritability and aggression were more severe among youth with CycD than among youth with nonbipolar diagnoses, but did not differ across bipolar disorder subtypes. Among youth seeking treatment for mental illness, irritability and IA are prevalent and nonspecific. Irritability and IA were uniquely related to our outcomes of social and general functioning, suggesting that it is worthwhile to assess each separately, in order to broaden our understanding of the characteristics and correlates of each.

Predictors and moderators of agreement between clinical and research diagnoses for children and adolescents.

OBJECTIVE: Diagnoses play an important role in treatment planning and monitoring, but extensive research has shown low agreement between clinician-generated diagnoses and those from structured diagnostic interviews. However, most prior studies of agreement have not used research diagnoses based on gold standard methods, and researchers need to identify characteristics of diagnostically challenging clients. This study examined agreement between youth diagnoses generated through the research-based LEAD (Longitudinal, Expert, and All Data) standard to clinician diagnoses. METHOD: Participants were 391 families seeking outpatient community mental health services for youths ages 6-18 (39.1% female, 88.2% African American). Youths and parents completed research interviews and clinic diagnoses were extracted from clinic records. LEAD diagnoses synthesized results of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (KSADS-PL) and the youth's developmental, family, and psychiatric history. RESULTS: Agreement between the LEAD and chart diagnoses was low, not exceeding "poor" agreement for most diagnostic categories (κs = .10-.46, median = .37). Disagreement was largely driven by missed diagnoses, although clinicians also did assign extra diagnoses for some clients. Fewer diagnostic errors occurred when the youth's clinical picture was more clear (e.g., high or low symptom severity, lower comorbidity), when the youth was older, when the family was higher functioning, and when the parent had more depression. However, youth and family characteristics explained very little of the variability in diagnostic errors. CONCLUSIONS: RESULTS support the need to investigate strategies to improve clinician diagnostic accuracy.

Clinical decision making about child and adolescent anxiety disorders using the Achenbach system of empirically based assessment.

Anxiety disorders are common among children but can be difficult to diagnose. An actuarial approach to the diagnosis of anxiety may improve the efficiency and accuracy of the process. The objectives of this study were to determine the clinical utility of the Achenbach Child Behavior Checklist (CBCL) and Youth Self Report (YSR), two widely used assessment tools, for diagnosing anxiety disorders in youth and to aid clinicians in incorporating scale scores into an actuarial approach to diagnosis through a clinical vignette. Demographically diverse youth, 5 to 18 years of age, were drawn from two samples; one (N = 1,084) was recruited from a research center, and the second (N = 651) was recruited from an urban community mental health center. Consensus diagnoses integrated information from semistructured interview, family history, treatment history, and clinical judgment. The CBCL and YSR internalizing problems T scores discriminated cases with any anxiety disorder or with generalized anxiety disorder from all other diagnoses in both samples (ps < .0005); the two scales had equivalent discriminative validity (ps > .05 for tests of difference). No other scales, nor any combination of scales, significantly improved on the performance of the Internalizing scale. In the highest risk group, Internalizing scores greater than 69 (CBCL) or greater than 63 (YSR) resulted in a Diagnostic Likelihood Ratio of 1.5; low scores reduced the likelihood of anxiety disorders by a factor of 4. Combined with other risk factor information in an actuarial approach to assessment and diagnosis, the CBCL and YSR Internalizing scales provide valuable information about whether a youth is likely suffering from an anxiety disorder.

Reward dysregulation and mood symptoms in an adolescent outpatient sample.

Research on bipolar spectrum disorders (BPSD) in adolescence has burgeoned in the last decade, but continued work is needed to identify endophenotypic markers associated with illness onset and course. The present study examined reward dysregulation--measured via the behavioral activation system (BAS)--as one putative marker of BPSD in adolescence. A diverse group of 425 outpatient adolescents between 11 and 17 years of age (52 % male) completed the Behavioral Inhibition and Activation Scale (BIS-BAS) scale to measure reward dysregulation. Semi-structured interviews determined diagnoses and severity of mood symptoms. Parent-reported BAS was associated with increased symptoms of mania, and parent and adolescent-reported BAS were associated with symptoms of depression. Parent-reported BIS scores were associated with increased symptoms of mania. Results held independent of diagnostic status. Furthermore, parent BIS/BAS reports were stronger predictors for manic symptoms compared to adolescent-reports. Results extend work in adults with BPSD, suggesting a transdiagnostic association between reward dysregulation and mood symptom severity in adolescence.

An inexpensive family index of risk for mood issues improves identification of pediatric bipolar disorder.

Family history of mental illness provides important information when evaluating pediatric bipolar disorder (PBD). However, such information is often challenging to gather within clinical settings. This study investigates the feasibility and utility of gathering family history information using an inexpensive method practical for outpatient settings. Families (N=273) completed family history, rating scales, and the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998) and the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997) about youths 5-18 (median=11) years of age presenting to an outpatient clinic. Primary caregivers completed a half-page Family Index of Risk for Mood issues (FIRM). All families completed the FIRM quickly and easily. Most (78%) reported 1+ relatives having a history of mood or substance issues (M=3.7, SD=3.3). A simple sum of familial mood issues discriminated cases with PBD from all other cases (area under receiver operating characteristic [AUROC]=.63, p=.006). FIRM scores were specific to youth mood disorder and not attention-deficit/hyperactivity disorder or disruptive behavior disorder. FIRM scores significantly improved the detection of PBD even controlling for rating scales. No subset of family risk items performed better than the total. Family history information showed clinically meaningful discrimination of PBD. Two different approaches to clinical interpretation showed validity in these clinically realistic data. Inexpensive and clinically practical methods of gathering family history can help to improve the detection of PBD.

Evidence-based assessment strategies for pediatric bipolar disorder.

Evidence-based assessment of pediatric bipolar disorder has advanced rapidly in the last two decades, moving from isolated clinical case descriptions to what is now a portfolio of techniques that include checklists from multiple informants, semi-structured diagnostic interviews and severity ratings, and technologies that allow daily tracking of mood and energy over the course of treatment. This review critically appraises (a) the need for evidence-based assessment of bipolar disorder as a common component of clinical practice, (b) triggers that warrant assessment of bipolar, (c) when best to deploy different techniques over the course of diagnosis and treatment, and (d) promising new developments in assessment. A decision-making framework is adapted from evidence-based medicine to guide assessment sequences in a patient-centered approach. Emphasis is placed on approaches that currently have the best validity and are feasible in most clinical practice settings. These methods increase accuracy and address many controversies surrounding pediatric bipolar diagnoses.

The effects of including a callous-unemotional specifier for the diagnosis of conduct disorder.

BACKGROUND: 'With Significant Callous-Unemotional Traits' has been proposed as a specifier for conduct disorder (CD) in the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The impact of this specifier on children diagnosed with CD should be considered. METHODS: A multi-site cross-sectional design with volunteers (n = 1136) in the third-seventh grades and 566 consecutive referrals (ages 5-18) to a community mental health center were used to estimate the prevalence rates of CD with and without the proposed specifier. In addition, the degree of emotional and behavioral (especially physical aggression) disturbance and level of impairment in youth with and without CD and with and without the specifier was evaluated. RESULTS: In the community sample, 10%-32% of those with CD and 2%-7% of those without CD met the callous-unemotional (CU) specifier threshold depending on informant. In the clinic-referred sample, 21%-50% of those with CD and 14%-32% without CD met the CU specifier threshold depending on informant. Those with CD and the specifier showed higher rates of aggression in both samples and higher rates of cruelty in the clinic-referred sample. CONCLUSIONS: Results indicate between 10% and 50% of youth with CD would be designated with the proposed CU specifier. Those with CD and the specifier appear to be more severe on a number of indices, including aggression and cruelty.

Portability of a screener for pediatric bipolar disorder to a diverse setting.

Robust screening measures that perform well in different populations could help improve the accuracy of diagnosis of pediatric bipolar disorder. Changes in sampling could influence the performance of items and potentially influence total scores enough to alter the predictive utility of scores. Additionally, creating a brief version of a measure by extracting items from a longer scale might cause differential functioning due to context effects. The authors of current study examined both sampling and context effects of a brief measure of pediatric mania. Caregivers of 813 youths completed the parent-reported version of the General Behavior Inventory (PGBI) at an academic medical center sample enriched for mood disorders. Caregivers of 481 youths completed the PGBI at a community mental health center. Caregivers of 799 youths completed 10 items extracted from the PGBI at a community setting. Caregivers of 159 youths completed both versions of the PGBI and a semistructured diagnostic interview. Differential item functioning indicated that across samples some items functioned differently; however, total observed scores were similar across all levels of mania. Receiver operating characteristic analysis indicated that the 10 extracted items discriminated bipolar disorder from nonbipolar behavior as well as when the items were embedded within the full measure. Findings suggest that the extracted items perform similarly to the embedded items in the community setting. Measurement properties appear sufficiently robust across settings to support clinical applications.

Generalizability of evidence-based assessment recommendations for pediatric bipolar disorder.

Bipolar disorder is frequently clinically diagnosed in youths who do not actually satisfy Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR; American Psychiatric Association, 1994) criteria, yet cases that would satisfy full DSM-IV-TR criteria are often undetected clinically. Evidence-based assessment methods that incorporate Bayesian reasoning have demonstrated improved diagnostic accuracy and consistency; however, their clinical utility is largely unexplored. The present study examines the effectiveness of promising evidence-based decision-making strategies compared with the clinical gold standard. Participants were 562 youths, ages 5 to 17 and predominantly African American, drawn from a community mental health clinic. Research diagnoses combined a semistructured interview with youths' psychiatric, developmental, and family mental health histories. Independent Bayesian estimates that relied on published risk estimates from other samples discriminated bipolar diagnoses (area under curve = .75, p < .00005). The Bayes and confidence ratings correlated at rs = .30. Agreement about an evidence-based assessment intervention threshold model (wait/assess/treat) was κ = .24, p < .05. No potential moderators of agreement between the Bayesian estimates and confidence ratings, including type of bipolar illness, were significant. Bayesian risk estimates were highly correlated with logistic regression estimates using optimal sample weights (r = .81, p < .0005). Clinical and Bayesian approaches agree in terms of overall concordance and deciding next clinical action, even when Bayesian predictions are based on published estimates from clinically and demographically different samples. Evidence-based assessment methods may be useful in settings in which gold standard assessments cannot be routinely used, and they may help decrease rates of overdiagnosis while promoting earlier identification of true cases.

Informants are not all equal: predictors and correlates of clinician judgments about caregiver and youth credibility.

OBJECTIVE: The objectives of this study were to examine how often clinicians judged youths or caregivers to not be credible informants, to identify the associated features of youth or caregiver credibility, and to examine credibility's impact on the validity of mood and behavior checklists. BACKGROUND: Clinicians often have the experience of talking to a parent or a youth and judging that the credibility of the information offered is unusually poor. Little is known about the correlates of poor credibility or about the extent to which credibility changes the validity of commonly used checklists. METHODS: Interviewers rated the credibility of 646 youths aged 5-18 and their primary caregivers after completing a Kiddie Schedule for Affective Disorders and Schizophrenia. Ratings and diagnoses were blind to the behavior checklists completed by caregivers, youths, and teachers. A subset of youths also had intelligent quotient tests and behavioral observations available. RESULTS: Caregivers were perceived as more credible on average than youths, though this dropped sharply with adolescents. Caregiver credibility was higher for better functioning families, more credible youths, younger youths, and more educated caregivers; it was unrelated to caregiver mood symptoms or being the mother. Youth credibility was strongly connected to age, cognitive ability, caregiver credibility, and independent observations of youth behavior. Credibility ratings markedly altered the validity of checklists compared with interview ratings, diagnoses, or cross-informant criteria. CONCLUSION: Clinicians' judgments about informant credibility are associated with different characteristics for youths versus caregivers, though youth age is important to both. Credibility affects the validity of information from checklists measured against several different independent criteria.

Is caregiver-adolescent disagreement due to differences in thresholds for reporting manic symptoms?

INTRODUCTION: Cross-informant disagreement is common and results in different interpretations of a youth's behavior. Theoretical explanations for discrepancies typically rely on scale level analyses. This article explores whether caregivers and adolescents differ in when they notice and report symptoms of youth mania depending on the severity of overall manic disturbance. METHOD: Participants were 459 adolescent-caregiver pairs recruited at either a community mental health center or an academic medical center. Adolescents were most likely to have a primary diagnosis of unipolar depression (37%) or attention-deficit/hyperactivity disorder/disruptive behavior disorder (36%). Nineteen percent of adolescents received a bipolar spectrum disorder diagnosis (4% bipolar I and 15% bipolar II, cyclothymia, or bipolar not otherwise specificed). Caregivers were primarily biological mothers (74%) or grandparents (8%). Adolescents and caregivers independently completed the Mood Disorder Questionnaire (MDQ) about the adolescent. RESULTS: Item response theory analyses of the entire sample indicated that in general, both caregivers and adolescents reserved endorsement of mania symptoms for the most severely ill half of participants. Comparisons of caregiver and adolescent report of symptoms on the MDQ indicated two significant differences. Caregivers were more likely to report irritability at significantly lower severity of mania than adolescents. Adolescents endorsed only increased energy or hyperactivity at lower severities than caregivers. CONCLUSIONS: Adolescents and caregivers will have different concerns and might report different symptoms consistent with whom the symptom impacts first. Caregivers are more likely to report behaviors such as irritability, whereas adolescents are more likely to report subjective feelings such as feeling more energetic or more hyperactive.

Evidence-Based Strategies Improve Assessment of Pediatric Bipolar Disorder by Community Practitioners.

The misdiagnosis of pediatric bipolar disorder (PBD) has become a major public health concern. Would available evidence-based assessment (EBA) strategies help improve diagnostic accuracy, and are clinicians willing to consider these strategies in practice? The purpose of the present study was to document the extent to which using an EBA decision tool--a probability nomogram--improves the interpretation of family history and test data by clinicians and to examine the acceptability of the nomogram technique to clinicians. Over 600 clinicians across the US and Canada attending continuing education seminars were trained to use the nomogram. Participants estimated the probability that a youth in a clinical vignette had bipolar disorder, first using clinical judgment and then using the nomogram. Brief training of clinicians (less than 30 minutes) in using the nomogram for assessing PBD improved diagnostic accuracy, consistency, and agreement. The majority of clinicians endorsed using the nomogram in practice. EBA decision aids, such as the nomogram, may lead to a significant decrease in overdiagnosis and help clinicians detect true cases of PBD.

Examining the validity of cyclothymic disorder in a youth sample.

BACKGROUND: Four subtypes of bipolar disorder (BP) - bipolar I, bipolar II, cyclothymia and bipolar not otherwise specified (NOS) - are defined in DSM-IV-TR. Though the diagnostic criteria for each subtype are intended for both adults and children, research investigators and clinicians often stray from the DSM when diagnosing pediatric bipolar disorder (PBD) (Youngstrom, 2009), resulting in a lack of agreement and understanding regarding the PBD subtypes. METHODS: The present study uses the diagnostic validation method first proposed by Robins and Guze (1970) to systematically evaluate cyclothymic disorder as a distinct diagnostic subtype of BP. Using a youth (ages 5-17) outpatient clinical sample (n=827), participants with cyclothymic disorder (n=52) were compared to participants with other BP spectrum disorders and to participants with non-bipolar disorders. RESULTS: Results indicate that cyclothymic disorder shares many characteristics with other bipolar subtypes, supporting its inclusion on the bipolar spectrum. Additionally, cyclothymia could be reliably differentiated from non-mood disorders based on irritability, sleep disturbance, age of symptom onset, comorbid diagnoses, and family history. LIMITATIONS: There is little supporting research on cyclothymia in young people; these analyses may be considered exploratory. Gaps in this and other studies are highlighted as areas in need of additional research. CONCLUSIONS: Cyclothymic disorder has serious implications for those affected. Though it is rarely diagnosed currently, it can be reliably differentiated from other disorders in young people. Failing to accurately diagnose cyclothymia, and other subthreshold forms of bipolar disorder, contributes to a significant delay in appropriate treatment and may have serious prognostic implications.

Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation?

OBJECTIVE: Pediatric bipolar disorder (PBD) involves a potent combination of mood dysregulation and interpersonal processes, placing these youth at significantly greater risk of suicide. We examined the relationship between suicidal behavior, mood symptom presentation, family functioning, and quality of life (QoL) in youth with PBD. METHODS: Participants were 138 youths aged 5-18 years presenting to outpatient clinics with DSM-IV diagnoses of bipolar I disorder (n=27), bipolar II disorder (n=18), cyclothymic disorder (n=48), and bipolar disorder not otherwise specified (n=45). RESULTS: Twenty PBD patients had lifetime suicide attempts, 63 had past or current suicide ideation, and 55 were free of suicide ideation and attempts. Attempters were older than nonattempters. Suicide ideation and attempts were linked to higher depressive symptoms, and rates were even higher in youths meeting criteria for the mixed specifier proposed for DSM-5. Both suicide ideation and attempts were associated with lower youth QoL and poorer family functioning. Parent effects (with suicidality treated as outcome) and child effects (where suicide was the predictor of poor family functioning) showed equally strong evidence in regression models, even after adjusting for demographics. CONCLUSIONS: These findings underscore the strong association between mixed features and suicidality in PBD, as well as the association between QoL, family functioning, and suicidality. It is possible that youths are not just a passive recipient of family processes, and their illness may play an active role in disrupting family functioning. Replication with longitudinal data and qualitative methods should investigate both child and parent effect models.

Diagnostic and measurement issues in the assessment of pediatric bipolar disorder: implications for understanding mood disorder across the life cycle.

The goal of this paper is to review assessment research of bipolar disorder in children and adolescents. The review addresses numerous themes: the benefits and costs of involving clinical judgment in the diagnostic process, particularly with regard to diagnosis and mood severity ratings; the validity of parent, teacher, and youth self-report of manic symptoms; how much cross-situational consistency is typically shown in mood and behavior; the extent to which a parent's mental health status influences their report of child behavior; how different measures compare in terms of detecting bipolar disorder, the challenges in comparing the performance of measures across research groups, and the leading candidates for research or clinical use; evidence-based strategies for interpreting measures as diagnostic aids; how test performance changes when a test is used in a new setting and what implications this has for research samples as well as clinical practice; the role of family history of mood disorder within an assessment framework; and the implications of assessment research for the understanding of phenomenology of bipolar disorder from a developmental framework.