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Relationship of Persistent Manic Symptoms to the Diagnosis of Pediatric Bipolar Spectrum Disorders

Thomas W. Frazier, PhD; Eric A. Youngstrom, PhD; Sarah McCue Horwitz, PhD; Christine A. Demeter, MA; Mary A. Fristad, PhD, ABPP; L. Eugene Arnold, MD; Boris Birmaher, MD; Robert A. Kowatch, MD, PhD; David Axelson, MD; Neal Ryan, MD; Mary Kay Gill, MSN; and Robert L. Findling, MD

Published: March 22, 2011

Article Abstract

Objective: The diagnosis of bipolar spectrum disorders (BPSDs [bipolar I and II disorders, cyclothymic disorder, and bipolar disorder not otherwise specified]) in youth remains controversial. The present study evaluated the possibility that the presence of persistent manic symptoms over a relatively short interval may increase the probability of a BPSD DSM diagnosis.

Method: Data were obtained from the screening and baseline assessments collected from 2005 through 2008 of an ongoing prospective, longitudinal study (Longitudinal Assessment of Manic Symptoms) examining the diagnosis and phenomenology of youth (N = 692) presenting to outpatient centers at ages 6-12 years. Youth were assessed for elevated symptoms of mania (ESM) with the Parent General Behavior Inventory-10-Item Mania Scale (PGBI-10M), the primary outcome measure. Screening and baseline scores separated individuals into those with ESM (ESM+; PGBI-10M score ≥ 12) and a control group of youth without ESM (ESM-; PGBI-10M score < 12). Youth were classified into 4 groups: persistent ESM+, remitted ESM+, persistent ESM-, and progressed to ESM+.

Results: Individuals with persistent ESM+ were more likely to have a BPSD (relative risk = 3.04; 95% CI, 2.15-4.30). Using 2 administrations of the PGBI-10M spaced over a relatively brief interval (median = 4.0, mean = 6.1, SD = 5.9 weeks) improved the prediction of BPSD over using only the first administration (ΔR2 = 0.10, Δχ21 = 50.06, P < .001). Likelihood ratios indicated that persistent ESM- substantially decreased the probability of BPSD. While high levels of persistent ESM+ increased the probability of a BPSD diagnosis, the final positive predictive value was only sufficient to signify the need for more thorough clinical evaluation.

Conclusions: In many cases, obtaining repeated parent report of mania symptoms substantially altered the probability of a BPSD diagnosis and may be a useful adjunct to a careful clinical evaluation. Future waves of data collection from this longitudinal study will be crucial for devising clinically useful methods for identifying or ruling out pediatric BPSD.

J Clin Psychiatry

Submitted: February 26, 2010; accepted August 11, 2010.

Online ahead of print: March 22, 2011 (doi:10.4088/JCP.10m06081yel).

Corresponding author: Thomas W. Frazier, PhD, Center for Pediatric Behavioral Health and Center for Autism, Cleveland Clinic, 2801 Martin Luther King Jr Drive, Cleveland, OH 44104 (

Volume: 72

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