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We present early data on its reliability and validity in this report

The child bipolar questionnaire: a dimensional approach to screening for pediatric bipolar disorder.

Journal of Affective Disorders, no. 1 (2006): 149-158

Cited by: 45|Views14
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Abstract

The Child Bipolar Questionnaire (CBQ) is a rapid screener with a Core Index subscale of symptom dimensions frequently reported in childhood-onset bipolar disorder (BD) and scoring algorithms for DSM-IV BD, with and without attention-deficit/hyperactivity disorder (ADHD), and the proposed Narrow, Broad, and Core phenotypes. This report pro...More

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Introduction
  • Sharing some of the clinical features of adult-onset bipolar disorder (BD), childhood-onset BD often differs in duration and symptom quality from the adult criteria delineated in the American Psychiatric

    Association's (1994) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (Faedda et al, 1995).
  • A rapid screening instrument that assesses the symptoms of mania and multiple clinical dimensions commonly considered comorbid with BD in children may be of great value in facing the diagnostic challenge of parsing the overlapping symptom criteria of several childhood disorders (Papolos, 2003).
  • The Child Bipolar Questionnaire (CBQ) is a rapid screener with a Core Index subscale of symptom dimensions frequently reported in childhood-onset bipolar disorder (BD) and scoring algorithms for DSM-IV BD, with and without attentiondeficit/hyperactivity disorder (ADHD), and the proposed Narrow, Broad, and Core phenotypes.
Highlights
  • Sharing some of the clinical features of adult-onset bipolar disorder (BD), childhood-onset BD often differs in duration and symptom quality from the adult criteria delineated in the American Psychiatric

    Association's (1994) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (Faedda et al, 1995)
  • We provide preliminary findings on the reliability and validity of the Child Bipolar Questionnaire (CBQ) in a sample of children recruited via the Juvenile Bipolar Research Foundation (JBRF) data acquisition system
  • In a prior study investigating the number of subjects in the larger JBRF database potentially meeting symptom criteria for each of the proposed alternate phenotypes for childhood-onset BD, screening algorithms were derived from CBQ items for the Narrow and Broad phenotypes (Leibenluft et al, 2003) and a Core phenotype proposed by the principal author (Papolos, in press)
  • Reliability of the CBQ screening algorithms was assessed by comparing the diagnosis indicated by the first rating for each subject to that indicated by the second rating using a kappa coefficient
  • If further validation efforts are successful, the CBQ may be used by the clinician to aid in the early detection of BD features, the parsing of symptom dimensions and the differentiation of comorbid conditions for treatment focus
  • An online scoring program for the CBQ is in development that provides total score and Core Index subscale score with diagnostic implications and a breakdown of symptom dimensions
Results
  • The correlations between the test and retest values of the CBQ total score and the CBQ Core Index subscale were 0.82 and 0.86 respectively
  • Both are considered in excellent agreement (Fleiss, 1981).
  • Reliability of the CBQ screening algorithms was assessed by comparing the diagnosis indicated by the first rating for each subject to that indicated by the second rating using a kappa coefficient.
  • The test–retest concordance estimates were 0.81 for BD, 0.74 for ADHD, and 0.76 for neither diagnosis, all considered in excellent agreement
Conclusion
  • Some of the most difficult questions surrounding childhood-onset bipolar disorder have to do with phenomenological issues.
  • This report has presented preliminary psychometric data on the Child Bipolar Questionnaire, a 65 item parent-report rating scale that takes approximately 10 min to complete and lends itself to selfadministration via the internet or to administration by a clinician
  • This screening instrument was originally designed as a research tool to rapidly identify potential BD cases for diagnostic confirmation and to assist in defining subgroups for genotyping.
  • An online scoring program for the CBQ is in development that provides total score and Core Index subscale score with diagnostic implications and a breakdown of symptom dimensions
Tables
  • Table1: Proposed alternative phenotypes for childhood-onset BD
  • Table2: CBQ-derived screening algorithms
  • Table3: CBQ Core Index subscale
  • Table4: Associations of CBQ scores with selected psychiatric history events among 497 children/adolescents with supplemental questionnaire data
Download tables as Excel
Funding
  • 3.03, p = 0.003 a z-statistic calculated using generalized linear modeling methods (Gaussian family), adjusting for age and sex, with robust estimation of standard errors
Study subjects and analysis
data: 350
For the CBQ, 85 items were drawn from DSM-IV symptom criteria for mania, major depression, and common comorbid conditions: separation anxiety disorder, generalized anxiety disorder, obsessive–compulsive disorder, oppositional defiant disorder, conduct disorder, and attention-deficit disorder. Parents of a clinical sample of children diagnosed with bipolar disorder (n = 350) were asked to rate the items on a Likert scale: “1” (“never”), “2” (“sometimes”), “3” (“often”), or “4” (“very often or almost constantly”). Those items rated “2” or higher by > 70% of the parents were rank-ordered according to frequency of occurrence

data: 2795
Construction of the CBQ Core Index subscale. In a separate prior study, a series of principal component factor analyses with Varimax rotation were carried out on CBQ data from a large subsample of the JBRF data set (n = 2795) to test a hypothesis concerning the core symptom dimensions of childhood-onset BD (Papolos, in press). The CBQ items loading on the resulting factors comprise the Core Index subscale (see Table 3)

data: 2427
Reliability assessment included three different methods: internal consistency assessment, test–retest agreement, and inter-rater (virtually always, inter-parent) concordance. The internal consistency estimation was performed on a large CBQ data set (n = 2427) using Cronbach's alpha procedure. The test–retest procedure was conducted by requesting via email that the first 100 consecutive parents submitting CBQ data over the course of 3 months repeat their ratings within 7 days of their initial ratings

consecutive parents: 100
The internal consistency estimation was performed on a large CBQ data set (n = 2427) using Cronbach's alpha procedure. The test–retest procedure was conducted by requesting via email that the first 100 consecutive parents submitting CBQ data over the course of 3 months repeat their ratings within 7 days of their initial ratings. In this manner, test–retest data was collected on 108 children

children: 108
The test–retest procedure was conducted by requesting via email that the first 100 consecutive parents submitting CBQ data over the course of 3 months repeat their ratings within 7 days of their initial ratings. In this manner, test–retest data was collected on 108 children. The inter-rater reliability assessment was conducted similarly, with 50 consecutive parents requested to ask another parent or close family member to separately rate their child/adolescent within 7 days of each other

consecutive parents: 50
In this manner, test–retest data was collected on 108 children. The inter-rater reliability assessment was conducted similarly, with 50 consecutive parents requested to ask another parent or close family member to separately rate their child/adolescent within 7 days of each other. Inter-rater reliability data was collected on 48 children in this manner

children: 48
The inter-rater reliability assessment was conducted similarly, with 50 consecutive parents requested to ask another parent or close family member to separately rate their child/adolescent within 7 days of each other. Inter-rater reliability data was collected on 48 children in this manner. Reliability of the CBQ total score, the CBQ Core Index subscale, and the CBQ-based screening algorithms was assessed

children: 135
Eligibility for these studies required diagnostic confirmation via administration of the K-SADS P/L diagnostic interview to both parent and child. Parents and 135 children were interviewed by four graduate-level interviewers trained in the administration of the K-SADS P/L by the JBRF project director, who had been approved after training with Dr Joan Kaufman. Three diagnostic groups were represented in the sample: BD (inclusive of BP I, BP II, and BP-NOS), ADHD-only, and no psychiatric diagnosis

children: 497
In addition, the CBQ Core Index subscale was assessed for its ability to predict membership in the three diagnostic groups. Parents of a separate subsample of 497 children from the larger data set, 325 of whom had a community diagnosis of bipolar disorder, provided additional experiential and behavioral histories, such as prior psychiatric hospitalizations, school difficulties, and involvement with the juvenile justice system. Concurrent validity was examined in this sample to determine whether CBQ total score differed among subgroups with differential experiences

data: 2427
Internal consistency Cronbach [alpha] coefficient was calculated to evaluate the internal consistency of the CBQ. In subjects reported by their parents to have a clinician-assigned diagnosis of bipolar disorder, the alpha estimate for the CBQ was 0.929 (n = 2427). 3.1.2

subjects: 19
In this comparison three classifications were used: BD (DSM-IV phenotype), ADHD-only, and neither psychiatric diagnosis (see Table 2 for screening algorithms). Based on the first rating, 85 (79%) were classified as BD, 19 subjects (18%) were classified as ADHD, and 4 subjects (4%) were classified as having neither diagnosis. Within diagnostic group, the test–retest concordance estimates were 0.81 for BD, 0.74 for ADHD, and 0.76 for neither diagnosis, all considered in excellent agreement

subjects: 48
3.1.3. Inter-rater (inter-parent) reliability Each of 48 subjects was rated once by each of two different raters using the CBQ. In all cases, the first responder was the mother of the child while the second responder was most often the father (79%)

subjects: 12
Reliability of the CBQ screening algorithms was assessed by comparing the diagnosis indicated by the first rating to that indicated by the second rating using a kappa coefficient. The correlations within diagnostic group were similar to that for the full set of subjects: for the ADHD subjects (n = 12) the correlation was 0.54, and for the BD subjects (n = 35) the correlation was 0.53. These findings are comparable to the typical levels of inter-rater agreement between adults describing a child's behavior in the same setting (Achenbach et al, 1987)

subjects: 76
3.2.1. CBQ screening algorithms Using the KSADS P/L, 76 subjects (56%) were diagnosed with BD (DSM-IV phenotype), 21 subjects (16%) with ADHD without mood disorder, and 38 subjects (28%) with no psychiatric diagnosis. Of the 76 subjects diagnosed with BD, 26 were diagnosed with Bipolar I Disorder, 5 with Bipolar II Disorder, and 45 with Bipolar Disorder, Not Otherwise Specified (BPNOS)

subjects: 76
CBQ screening algorithms Using the KSADS P/L, 76 subjects (56%) were diagnosed with BD (DSM-IV phenotype), 21 subjects (16%) with ADHD without mood disorder, and 38 subjects (28%) with no psychiatric diagnosis. Of the 76 subjects diagnosed with BD, 26 were diagnosed with Bipolar I Disorder, 5 with Bipolar II Disorder, and 45 with Bipolar Disorder, Not Otherwise Specified (BPNOS). Those diagnosed with BP-NOS had manic symptoms of briefer duration than required by DSMIV; the majority of these had rapid alternation of mood states within the same day

subjects: 59
Those diagnosed with BP-NOS had manic symptoms of briefer duration than required by DSMIV; the majority of these had rapid alternation of mood states within the same day. The CBQ screening algorithm for BD (DSM-IV phenotype) correctly classified 57 of 59 subjects who did not have BD (specificity = 97%) and 58 of 76 subjects who had BD (sensitivity = 76%), yielding an overall kappa of 0.71. Using the CBQ screening algorithms to differentiate between three diagnostic groups, there was an overall kappa of 0.69 (fair to good agreement) with an overall rate of agreement of 81%

ADHD subjects: 21
The CBQ screening algorithm correctly classified all but 1 of the subjects with no psychiatric diagnosis (97% correct screening). Fourteen of the 21 ADHD subjects (67%) were correctly classified, and 58 of the 76 BD subjects were correctly classified (76%). 3.2.2

subjects: 38
The dependent variable used in this analysis was the K-SADS diagnosis using the three groups: BD, ADHD, and no psychiatric diagnosis. From this analysis it was determined that if the CBQ Core Index subscale score was 0 or 1, a subject should be classified as having no diagnosis; 36 out of the 38 subjects (95%) were correctly classified. A subject with a CBQ Core Index score of 2 or 3 was predicted to have ADHD-only

subjects: 76
Using the CBQ to classify subjects into subgroups with and without comorbid ADHD. Of the 76 subjects diagnosed with BD using the KSADS P/L, 51 were diagnosed with comorbid ADHD. The ability of the CBQ to differentiate those BD cases with ADHD from those without was explored using logistic regression

BD subjects with ADHD: 51
In simplified form, an algorithm for classifying subjects was proposed: if both item 11 and item 14 are rated 3 or higher, then BD with ADHD is indicated; if at most one of the items is rated 3 or higher, then BD without ADHD is indicated. This rule correctly identified 39 of the 51 BD subjects with ADHD (77%) and 17 of the 25 BD subjects without ADHD (68%). 3.2.4

subjects: 497
3.2.4. Concurrent validity Additional history data were obtained from the parents of a subsample of 497 subjects, 325 of whom had a community diagnosis of bipolar disorder. These supplemental data included information such as age of onset of psychiatric difficulties; current and first psychiatric diagnoses; whether or not there was a history of psychiatric hospitalization and, if so, how many inpatient stays; duration of periods of mood stability/instability, school difficulties (whether held back in school); and presence/absence of involvement with the juvenile justice system

children: 76
First is the lack of fit of the DSM-IV mania-based screening algorithm with the clinical presentation of most of the children in the sample. Of the 76 children given a K-SADS P/L. diagnoses of bipolar disorder, only 26 were diagnosed with BP I

subjects: 45
diagnoses of bipolar disorder, only 26 were diagnosed with BP I. The majority of the children, 45 subjects, were diagnosed with BP-NOS, a diagnosis that was recommended for these children by experts at the NIMH 2001 Roundtable on Prepubertal Bipolar Disorder in the absence of a more appropriate phenotype (NIMH, 2001). The CBQ Core Index subscale, a measure based on analysis of symptom dimensions, performed better than the BD and ADHD screening algorithms when compared to K-SADS diagnoses, with a kappa coefficient indicating excellent agreement

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