What is the General Behaviour Inventory?

Introduction

The General Behavior Inventory (GBI) is a 73-question psychological self-report assessment tool designed by Richard Depue and colleagues to identify the presence and severity of manic and depressive moods in adults, as well as to assess for cyclothymia.

It is one of the most widely used psychometric tests for measuring the severity of bipolar disorder and the fluctuation of symptoms over time. The GBI is intended to be administered for adult populations; however, it has been adapted into versions that allow for juvenile populations (for parents to rate their offspring), as well as a short version that allows for it to be used as a screening test.

Refer to Hypomania Checklist.

Versions

General Behaviour Inventory (GBI)

The GBI was originally made as a self-report instrument for college students and adults to use to describe their own history of mood symptoms. The original item set included clinical characteristics and associated features in addition to the diagnostic symptoms of manic and depressive states in the current versions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. The first set of 69 items was increased to 73, with the final version having 73 mood items and 6 additional questions to check the validity of responses (but which did not figure in the scale scores). The self report version of the GBI has been used in an extensive programme of research, accruing evidence of many facets of validity. Because of its length and high reading level, there also have been many efforts to develop short forms of the GBI.

7 Up 7 Down Inventory (7U7D)

The 7 Up-7 Down (7U7D) is a 14-item measure of manic and depressive tendencies that was carved from the full length GBI. This version is designed to be applicable for both youths and adults, and to improve separation between both mania and depressive conditions. It was developed via factor analysis from nine separate samples pooled into two age groups, ensuring applicability for use in youth and adults.

A sleep scale also has been carved from the GBI, using the seven items that ask about anything directly related to sleep.

Parent Report on the GBI (P-GBI)

The P-GBI is an adaptation of the GBI, consisting of 73 Likert scale items rated on a scale from 0 (“Never or Hardly Ever”) to 3 (“Very often or Almost Constantly”). It consists of two scales: a depressive symptoms (46 items) and a hypomanic/biphasic (mixed) symptoms (28 items).

Parent Short Forms

Again, due to the length of the full version, several short forms have been built and tested in multiple samples that may be more convenient to use in clinical work. These include 10 item mania, two alternate 10 item depression forms, and the seven item Sleep scale. All have performed as well or better than the self-report version when completed by an adult familiar with the youth’s behaviour (typically a parent).

The PGBI-10M is a brief (10-item) version of the PGBI that was validated for clinical use for patients presenting with a variety of different diagnoses, including frequent comorbid conditions. It is administered to parents for them to rate their children between ages 5-17. The 10 items include symptoms such as elated mood, high energy, irritability and rapid changes in mood and energy as indicators of potential juvenile bipolar disorder. The PhenX Toolkit uses this instrument as its child protocol for Hypomania/Mania Symptoms.

Teacher Report on the GBI

One study had a large sample of teachers complete the GBI to describe the mood and behaviour of youths age 5 to 18 years old. The results indicated that there were many items that teachers did not have an opportunity to observe the behaviour (such as the items asking about sleep), and others that teachers often chose to skip. Even after shortening the item list to those that teachers could report about, the validity results were modest even though the internal consistency reliability was high. The results suggested that it was challenging for teachers to tell the difference between hypomanic symptoms and symptoms attributable to attention-deficit/hyperactivity disorder, which is much more common in the classroom. The results aligned with findings from a large meta-analysis that teacher report had the lowest average validity across all mania scales compared to adolescent or parent report on the same scales. Based on these results, current recommendations are to concentrate on parent and youth report, and not use teacher report as a way of measuring hypomanic symptoms in youths.

Psychometric Properties

The GBI has been used extensively in research, including clinical samples, college students, longitudinal, treatment, and other studies. However, no normative data exist to calibrate scores in the general population.

Reliability

The GBI has exceptionally high internal consistency because it has long scales with a large number of items. The GBI shows high reliability whether completed as a self report or as a caregiver report about youth behaviour.

Retest reliability also is good over a week or two week period, although the GBI’s length makes it tedious to complete frequently.

Interpretation

GBI Scoring

The current GBI questionnaire includes 73 Likert-type items which reflect symptoms of different moods. The original version of the GBI used case scoring where items were given values ranging from 1-4. Symptoms that were rated as 1 or 2 were considered to be absent and symptoms rated as 3 or 4 were considered to be present. However, if each item were to receive one of four scores, the authors of the GBI decided Likert scaling would be a better scoring option. The items on the GBI are now scaled from 0-3 rated as 0 (never or hardly ever present), 1 (sometimes present), 2 (often present), and 3 (very often or almost constantly present).

PGBI-10M

For the PGBI-10M, the scores from each question are added together to form a total score, with higher scores indicating a greater severity of symptoms. Scores range from 0 to 30. Low scores of 5 and below indicate a very low risk of a bipolar diagnosis. High scores of 18 and over indicate a high risk of a diagnosis of bipolar disorder, increasing the likelihood by a factor of seven or greater. Several peer-reviewed research studies support the P-GBI as a reliable and valid measure of bipolar in children and adolescents. It is recommended to be used as part of an assessment battery in the diagnosis of juvenile bipolar disorder.

Limitations

The GBI is free for use clinically and in research. The reading level and length make it challenging for some people to complete. Being a self-report questionnaire, the GBI is not known to have any adverse effects on patients beyond the potential of causing minor distress.

Research

Shorter versions of the GBI have been validated for research and clinical use. For instance, the PGBI-10M is currently being tested as part of a large longitudinal study investigating the course of early symptoms of mania in children[citation needed], with preliminary studies indicating its clinical efficacy in differentiating juvenile bipolar disorder from youth with other diagnoses.

What is the Hypomania Checklist?

Introduction

The Hypomania Checklist (HCL-32) is a questionnaire developed by Dr. Jules Angst to identify hypomanic features in patients with major depressive disorder in order to help recognise bipolar II disorder and other bipolar spectrum disorders when people seek help in primary care and other general medical settings.

It asks about 32 behaviours and mental states that are either aspects of hypomania or features associated with mood disorders. It uses short phrases and simple language, making it easy to read. The University of Zurich holds the copyright, and the HCL-32 is available for use at no charge. More recent work has focused on validating translations and testing whether shorter versions still perform well enough to be helpful clinically. Recent meta-analyses find that it is one of the most accurate assessments available for detecting hypomania, doing better than other options at recognising bipolar II disorder.

Development and Brief History

The Hypomania Checklist was built as a more efficient screening measure for hypomania, to be used both in epidemiological research and in clinical use. Existing measures for bipolar disorder focused on identifying personality factors and symptom severity instead of the episodic nature of hypomania or the possible negative consequences in behavioural, affective, or cognitive changes associated. These measures were mostly used in non-clinical populations to identify individuals at risk and were not used as screening instruments. The HCL-32 is a measure intended to have high sensitivity to direct clinicians from many countries to diagnosing individuals in a clinical population with bipolar disorder, specifically bipolar II disorder.

Initially developed by Jules Angst and Thomas Meyer in German, the questionnaire was translated into English and translated back to German to ensure accuracy. The English version of the HCL has been used as the basis for translation in other languages through the same process. The original study that used the HCL in an Italian and a Swiss sample noted the measure’s high sensitivity and a lower sensitivity than other used measures.

The scale includes a checklist of 32 possible symptoms of hypomania, each rated yes or no. The rating “yes” would mean the symptom is present or this trait is “typical of me,” and “no” would mean that the symptom is not present or “not typical” for the person.

Limitations

The HCL suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them. Like all questionnaires, the way the instrument is administered can influence the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations may elicit a different response compared to administration via a postal survey.

Similar reliability scores were found when only using 16 item assessments versus the traditional 32-item format of the HCL-32. A score of at least 8 items was found valid and reliable for distinguishing Bipolar Disorder and Major Depressive Disorder. In a study, 73% of patients who completed the HCL-32 R1 were true bipolar cases identified as potential bipolar cases. However, the HCL-32 R1 does not accurately differentiate between Bipolar I and Bipolar II. However, the 16-item HCL has not been tested as a standalone section in a hospital setting. In addition, while the HCL-32 is a sensitive instrument for hypomanic symptoms, it does not distinguish between bipolar I and bipolar-II disorders. The HCL-32 has not been compared with other commonly used screening tools for bipolar disorder, such as the Young Mania Rating Scale (YMRS)and the General Behaviour Inventory (GBI). The online version of the HCL has been shown to be as reliable as the paper version.

What is the Schedule for Affective Disorders and Schizophrenia?

Introduction

The Schedule for Affective Disorders and Schizophrenia (SADS) is a collection of psychiatric diagnostic criteria and symptom rating scales originally published in 1978.

It is organised as a semi-structured diagnostic interview. The structured aspect is that every interview asks screening questions about the same set of disorders regardless of the presenting problem; and positive screens get explored with a consistent set of symptoms. These features increase the sensitivity of the interview and the inter-rater reliability (or reproducibility) of the resulting diagnoses. The SADS also allows more flexibility than fully structured interviews: Interviewers can use their own words and rephrase questions, and some clinical judgment is used to score responses.

There are three versions of the schedule:

  • The regular SADS;
  • The lifetime version (SADS-L); and
  • A version for measuring the change in symptomology (SADS-C).

Although largely replaced by more structured interviews that follow diagnostic criteria such as DSM-IV and DSM-5, and specific mood rating scales, versions of the SADS are still used in some research papers today.

Diagnoses Covered

The diagnoses covered by the interview include schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, anxiety disorders and a limited number of other fairly common diagnoses.

Relationship with the Research Diagnostic Criteria

The SADS was developed by the same group of researchers as the Research Diagnostic Criteria (RDC). While the RDC is a list of diagnostic criteria for psychiatric disorders, the SADS interview allows diagnoses based on RDC criteria to be made, and also rates subject’s symptoms and level of functioning.

K-SADS

The K-SADS (or Kiddie-SADS) is a version of the SADS adapted for school-aged children of 6–18 years. There are various different versions of the K-SADS, each varying slightly in terms of disorders and specific symptoms covered, as well as the scale range used. All of the variations are still semi-structured interviews, giving the interviewer more flexibility about how to phrase and probe items, while still covering a consistent set of disorders.

The K-SADS-E (Epidemiological version) was developed for epidemiological research. It focused on current issues and episodes only. Most of the items used a four point rating scale.

The K-SADS-PL (Present and Lifetime version) is administered by interviewing the parent(s), the child, and integrating them into a summary rating that includes parent report, child report, and clinical observations during the interview. The interview covers both present issues (i.e., the reason the family is seeking an evaluation) as well as past episodes of the disorders. Most items use a three point rating scale for severity (not present, subthreshold, and threshold – which combines both moderate and severe presentations). It has been used with preschool as well as school-aged children. A 2009 working draft removed all reference to the DSM-III-R criteria (which were replaced with the publication of the DSM-IV in 1994) and made some other modifications. A DSM-5 version is being prepared and validated.

The WASH-U K-SADS (Washington University version) added items to the depression and mania modules and used a six point severity rating for severity.

What are the Research Diagnostic Criteria (RDC)?

Introduction

The Research Diagnostic Criteria (RDC) are a collection of influential psychiatric diagnostic criteria published in late 1970s under auspices of Statistics Section NY Psychiatric Institute, authors were Spitzer, R L; Endicott J; Robins E. PMID 1153649; As psychiatric diagnoses widely varied especially between the USA and Europe, the purpose of the criteria was to allow diagnoses to be consistent in psychiatric research.

Some of the criteria were based on the earlier Feighner Criteria, although many new disorders were included; “The historical record shows that the small group of individuals who created the Feighner criteria instigated a paradigm shift that has had profound effects on the course of American and, ultimately, world psychiatry.”

The RDC is important in the history of psychiatric diagnostic criteria as the DSM-III was based on many of the RDC descriptions, head of DSM III Edition was R L Spitzer.

What is the Kiddie Schedule for Affective Disorders and Schizophrenia?

Introduction

The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) is a semi-structured interview aimed at early diagnosis of affective disorders such as depression, bipolar disorder, and anxiety disorder. There are currently four different versions of the test that are structured to include interviews with both the child and the parents or guardians.

The K-SADS serves to diagnose childhood mental disorders in school-aged children 6-18. The different adaptations of the K-SADS were written by different researchers and are used to screen for many affective and psychotic disorders. Versions of the K-SADS are semi-structured interviews administered by health care providers or highly trained clinical researchers, which gives more flexibility to the interviewer about how to phrase and probe items, while still covering a consistent set of disorders. Due to its semi-structured interview format, time to complete the administration varies based on the youth/adult being interviewed. Most versions of the K-SADS also include “probes”, if these are endorsed, another diagnostic category will be reviewed. If the probe is not endorsed, additional symptoms for that particular disorder will not be queried.

The K-SADS has been found to be reliable and valid in multiple research and treatment settings.

Refer to the Schedule for Affective Disorders and Schizophrenia (SADS).

Development and Brief History

The Schedule for Affective Disorders and Schizophrenia for School Aged Children, or K-SADS, was originally created as an adapted version of the Schedule for Affective Disorders and Schizophrenia, a measure for adults. The K-SADS was written by Chambers, Puig-Antich, et al. in the late 1970s. The K-SADS was developed to promote earlier diagnosis of affective disorders and schizophrenia in children in a way that incorporates reports by both the child and parent and a “summary score” by the interviewer based on observations and teacher ratings.

The first version of the K-SADS differed from other tests on children because it relied on answers to interview questions rather than observances during games and interactions. The 1990s led to the creation of different versions of the K-SADS for different purposes, such as ascertaining lifetime diagnoses (K-SADS-E) or focusing on current episodes (K-SADS-P).

Versions

KSADS-Present Version (KSADS-P)

The KSADS-P was the first version of the K-SADS, developed by Chambers and Puig-Antich in 1978 as a version of the Schedule for Affective Disorders and Schizophrenia adapted for use with children and adolescents 6-19 years old. This version rephrased the SADS to make the wording of the questionnaire pertain to a younger age group. For example, mania symptoms in children might be manifest differently than in adulthood (e.g. children might have not have the same opportunity to spend money impulsively, nor would they likely have access to credit cards or checking accounts; instead, they might give away all their favourite toys or empty their parent’s wallet to gain spending money). The KSADS-P is a structured interview given by trained clinicians or clinical researchers who interview both the child and the parent. This original version assesses symptoms that have occurred in the most current episode (within the week preceding the interview), as well as symptoms that have occurred within the last 12 months. The KSADS-P has many limitations: it does not assess lifetime symptoms and history, does not include many psychiatric diagnoses of interest in childhood (such as autistic spectrum disorders), and does not include diagnosis specific impairment ratings.

KSADS-Present and Lifetime Version (KSADS-PL)

The K-SADS-PL is used to screen for affective and psychotic disorders as well as other disorders, including, but not limited to Major Depressive Disorder, Mania, Bipolar Disorders, Schizophrenia, Schizoaffective Disorder, Generalized Anxiety, Obsessive Compulsive Disorder, Attention Deficit Hyperactivity Disorder, Conduct Disorder, Anorexia Nervosa, Bulimia, and Post-Traumatic Stress Disorder. This semi-structured interview takes 45-75 minutes to administer. It was written by Joan Kaufman, Boris Birmaher, David Brent, Uma Rao, and Neal Ryan. The majority of items in the K-SADS-PL are scored using a 0-3 point rating scale. Scores of 0 indicate no information is available; scores of 1 suggest the symptom is not present; scores of 2 indicate sub-threshold presentation and scores of 3 indicate threshold presentation of symptoms. The KSADS-PL has six components:

ComponentDescription
Unstructured Introductory Interview – Developmental HistoryThe first part of the interview asks about developmental history and the history of the presenting problem. The interviewer takes detailed notes on the record sheet. Prompts cover basic demographic information, physical and mental health history and prior treatments, current complaints, and the youth’s relations with friends, family, school, and hobbies. This section allows flexibility for the interviewer to collect more information on questions that need elaboration.
Diagnostic Screening InterviewThe diagnostic screening interview reviews the most severe current and past symptoms. There are probes and scoring criteria for each symptom presented. Symptoms of disorders are grouped into modules. If the patient does not display any current or past symptoms for the screening questions, then the rest of the module’s questions do not need to be asked.
Completion Checklist SupplementA supplemental checklist is used to screen for additional disorders.
Appropriate Diagnostic SupplementsThese supplements review presence/absence of symptoms for other disorders, including anxiety disorders, behavioural disorders, and substance abuse.
Summary Lifetime Diagnosis ChecklistBased on the previous sections, this section summarises which disorders have been present from first episode to now.
Children’s Global Assessment Scale (C-GAS)Scores the child’s level of functioning.

KSADS-Epidemiological (KSADS-E)

The KSADS-E, which is the epidemiological version of the KSADS, is a tool to interview parents about possible psychopathology in children from preschool onward. It was developed by Puig-Antich, Orvaschel, Tabrizi, and Chambers in 1980 as a structured interview. The tool examines both past and current episodes, focusing on the most severe past episode and the most current episode. However, this tool does not rate symptom severity; it should only be used to assess presence or absence of symptomatology. This version of the K-SADS introduced screening questions, which, if negative, allowed skipping the remaining diagnostic probes. Furthermore, the K-SADS-E also includes “skip out” criteria when assessing other diagnostic disorders (ADHD, PTSD, etc.), allowing those that screen positive to immediately be interviewed for all of the symptoms regarding that diagnosis, and those that screened negative could “skip out” of being interviewed on the remaining symptoms.

WASH-U-KSADS

The WASH-U version of the K-SADS was written by Barbara Geller and colleagues in 1996. It is a modified version of the 1986 K-SADS. This version is like many other versions of the K-SADS in that it is semi-structured, administered by clinicians to both parent and child separately, and assesses present episodes. However, this version specifically expands the mania section in order to be more applicable to pre-pubertal mania. In particular, it queries presence/absence of rapid cycling. It also includes a section on multiple other DSM-IV diagnoses, and examines both present and lifetime symptoms as well as symptom onset and offset items. These modifications made this specific version particularly useful for phenomenology studies.

KSADS Mania Rating Scale (KMRS) and Depression Rating Scale (KDRS)
It also is possible to use the items in the mania and depression modules of some versions of the KSADS to get an interview-based rating of the severity of mood problems. The KMRS and KDRS use a 1 to 6 rating format (the same as in the WASH-U, -P, and PL-Plus versions). Adding up the items provides a measure of the total symptom burden. The KMRS assess 21 symptoms related to mania, hypomania, and rapid cycling. Each item is rated on a 0-6 rating scale. Scores of 0 suggest no information is available (missing data); scores of 1 suggest the symptom is not present at all; scores of 2 suggest the symptom is slightly present; scores of 3 suggest the symptom is mildly severe; scores of 4 suggest the symptom is moderately severe; scores of 5 suggest the symptom is severe; and scores of 6 suggest the symptom is extremely severe. Items with scores of 4 or higher are clinically significant/problematic. Trained clinicians or clinical researchers administer the assessment to both the child and the parent, which each provide their own separate score for each item (P and C), and the total score encompasses the sum of all of the items (S).

The KMRS is an alternative to the Young Mania Rating Scale designed by Young et al. (frequently referred to as the YMRS). The YMRS is more well-known and widely used, but because it was written in 1978, it does not include all of the symptoms of mania from ICD-9 or ICD-10 (nor DSM-IV or DSM-5), as it predated them all. The YMRS was also designed for completion by nurses at the end of their eight-hour shift on an inpatient unit, observing adult patients. The KMRS has several advantages in comparison: It covers all the symptoms used in current versions of ICD and DSM, it was designed for use with children and teenagers, and it was written and validated as an interview. Studies have found excellent internal consistency and inter-rater reliability, as well as exceptionally high correlation with the YMRS. Similarly, the KDRS would be analogous to the Child Depression Rating Scale-Revised. The CDRS-R was also designed to be done as an interview, but the item content predates the current ICD and DSM and omits some important symptoms. The KDRS also shows strong reliability (internal consistency and inter-rater) and exceptionally high correlations with the KDRS.

Impact

The K-SADS is used to measure previous and current symptoms of affective, anxiety, psychotic, and disruptive behaviour disorders. The K-SADS has become one of the most widely used diagnostic interviews in research, particular for projects focused on mood disorders.

The K-SADS-PL has been written and translated into 16 different languages, including Korean, Hebrew, Turkish, Icelandic, and Persian. The K-SADS-PL is also available in several Indian dialects including Kannada, Marathi, Tamil and Telugu.

Limitations

One limitation of the K-SADS is that it requires extensive training to give properly, including observation techniques, score calibration, and re-checks to test inter-rater reliability.

What is the Child Mania Rating Scale?

Introduction

The Child Mania Rating Scales (CMRS) is a 21-item diagnostic screening measure designed to identify symptoms of mania in children and adolescents aged 9-17 using diagnostic criteria from the DSM-IV, developed by Pavuluri and colleagues.

There is also a 10-item short form. The measure assesses the child’s mood and behaviour symptoms, asking parents or teachers to rate how often the symptoms have caused a problem for the youth in the past month. Clinical studies have found the CMRS to be reliable and valid when completed by parents in the assessment of children’s bipolar symptoms. The CMRS also can differentiate cases of paediatric bipolar disorder from those with ADHD or no disorder, as well as delineating bipolar subtypes. A meta-analysis comparing the different rating scales available found that the CMRS was one of the best performing scales in terms of telling cases with bipolar disorder apart from other clinical diagnoses. The CMRS has also been found to provide a reliable and valid assessment of symptoms longitudinally over the course of treatment. The combination of showing good reliability and validity across multiple samples and clinical settings, along with being free and brief to score, make the CMRS a promising tool, especially since most other checklists available for youths do not assess manic symptoms.

Background

The Child Mania Rating Scale (CMRS) was created as a complement already existing measures like the Altman Self-Rating Mania Scale and the Young Mania Rating Scale, which were formulated for adults. The purpose of the CMRS is to both assess the symptoms of mania in paediatric bipolar disorder, and to accurately discriminate the symptoms of mania from symptoms of ADHD. It is important that the CMRS accurately discriminate from symptoms of ADHD because core symptoms of adolescent Bipolar Disorder and ADHD are shared between the two disorders: hyperactivity, impulsivity, and distractibility. The CMRS was designed specifically for younger children who may or may not have the ability to accurately answer questions about their behaviour. As a result, the questionnaire is filled out by parents are/or caregivers who work with the children on a daily basis. Previous mania scales were designed for use by either the clinician or the patient. Therefore, the CMRS is unique in that it allows parents and caregivers to contribute information about their child’s symptoms. This is especially important in cases where the child may be too young to fill out the questionnaires themselves.

Historically, effective rating and diagnosis of mania has been limited. Though many mania scales have been tested on adult populations, the Young Mania Rating Scale (YMRS) – which was tested against the child version (CMRS) as standard measure for screening mania- is the only adult scale that has also been studied for validity and reliability in prepubertal children. Previous attempts include the Beigel Scale/Manic State Rating Scale (MSRS) and the Patterson Scale, which used nurse and clinician reports to rate levels of mania. Neither scale effectively and consistently captured levels of mania in patients. Other measures of paediatric mania are generally limited because they are completed by the clinician, introducing potential for bias, and because they lack the depth necessary to differentiate between patient-specific ways in which symptoms are presented. The CMRS Parent and Teacher versions attempt to address some of the limitations by including a checklist that can gather information about behaviour at home, school, and other settings, rather than focusing only on what a clinician could directly observe. One study examined the accuracy of a shortened version of the CMRS-P, which included only 10 items, and found that its accuracy was similar to the full scale.

Typically, the CMRS takes only 10-15 minutes to administer. The questions ask about behaviour-specific actions and tendencies the child may have exhibited within the past month. The parent rates the behaviour on a scale from 1 to 4, where 1=never/rarely, 2=sometimes, 3=often, and 4=very often. A clinician examines the total score and determines if the child has ADHD or Bipolar Disorder. If a diagnosis Bipolar Disorder is deemed to be appropriate, the clinician will also determine the sub-type.

Versions

There is a short version (10 items) of the CMRS called the Brief CMRS/Brief CMRS-P. The shorter version was created because a shorter version is preferred to longer assessments if the shorter gives similar accuracy, which it does. Additionally, there is a teacher’s version of the CMRS called the CMRS-Teacher (CMRS-T).

Reliability and Validity

Reliability

Table 1: Rubric for evaluating norms and reliability for the Child Mania Rating Scale.

CriterionRating (Adequate, Good, Excellent, Too Good)Explanation
NormsN/A
Internal Consistency (Cronbach’s Alpha, Split Half, etc.)Excellent, too good for some texts.Alphas routinely over .96
Inter-rater ReliabilityN/ADesigned originally as a self-report scale; parent and youth report correlate about the same as cross-informant scores correlate in general.
Test-Retest ReliabilityAdequater = .96 over 1 week. Data on test-retest reliability over longer periods are needed.
RepeatabilityNot publishedNo published studies formally checking repeatability.

Construct validity analyses (Exploratory Factor Analysis and Confirmatory Factor Analysis) for the CMRS-P indicated that the scale is unidimensional. Internal consistency measured by Cronbach’s alpha was .96 in a sample consisting of ADHD, Bipolar, and healthy control participants. In a sample of participants with bipolar disorder, the cronbach’s alpha was 91. Additionally, it has the ability to accurately differentiate paediatric bipolar disorder from ADHD and healthy controls greater than 90% of the time.

The teacher version (CMRS-T) also has 21 items. The internal consistency, measured by Cronbach’s alpha, was .86. Correlations between the parent and teacher versions of the CMRS range from .23 to .27. The CMRS teacher version has not been shown to discriminate bipolar from nonbipolar cases at better than chance levels and is not recommended for use in clinical practice for diagnosing bipolar disorder in children.

Validity

Table 2: Evaluation of validity and utility for the Child Mania Rating Scale

CriterionRating (Adequate, Good, Excellent, Too Good)Explanation
Content ValidityExcellentCovers both DSM diagnostic symptoms and a range of associated features. Consistently distinguishes between PBP sub-types and comorbid disorders.
Construct Validity (e.g. Predictive, Concurrent, Convergent, and Discriminant Validity)ExcellentShows convergent validity with other symptom scales. Correlations between CMRS-P and other several clinician-rating scales intended to measure manic symptoms (e.g. Washington University Schedule for Affective Disorder and Schizophrenia mania module, the Schedule for Affective Disorders and Schizophrenia Mania Rating Scale, and the Young Mania Rating Scales) were excellent (.78 to .98).
Discriminative ValidityExcellent/Too GoodPreliminary studies show that CMRS scores discriminate cases with unipolar and bipolar mood disorders from other clinical disorders. AUCs of >.90 are quite high. Comparison to healthy controls might imply unrealistic performance when compared to realities of clinical practice.
Validity GeneralisationAdequateShown to be effective for ethnically representative samples. More research and multiple settings are needed to sufficiently determine generalization.
Treatment SensitivityGoodThe CMRS-P has also been found to be sensitive in detecting symptom change over the course of treatment in multiple studies.
Clinical UtilityExcellentFree (public domain), designed to be completed in 10-15 minutes, preliminary data are promising. Less research than some of the other contenders, but easier reading level than General Behaviour Inventory and more sensitive to treatment effects than Mood Disorder Questionnaire.

Development and History

The CMRS was developed as a shorter, reliable, and valid parent-report screening instrument for mania. The short form was derived from the CMRS 21 item scale which is the first original mania rating scale developed for children and adolescents. It was not developed from the Young Mania Rating Scale (YMRS) that was originally designed for adults, ‘Young’ being the name of the author than the fact that it was a scale for ‘young’ population. The YMRS was derived from the Parent-Young Mania Rating Scale (P-YMRS). This scale, developed from the YMRS, was created for use with adult inpatients. The items of the P-YMRS did not include the updated DSM-IV criteria for adolescent Bipolar Disorder, and it includes several items with poor factor loadings. Furthermore, the content is not developmentally appropriate for children, as many of the items require insight or appearance, which are irrelevant to young children. Another promising measure is the GBI as it has good psychometric properties. However, the GBI is lengthy and complicated and requires the child to have at least a 7th-grade reading ability. One of the most widely used measures of mania symptoms is the Kiddie Schedule for Affective Disorders and Schizophrenia mania section. However, this measure is extremely extensive and requires much clinical training to administer.

During the development of the CMRS, researchers found that reliable and more accurate diagnostic accuracy is found in parent reports in comparison to teacher reports or self-reports and that these other reports rarely added new information to the parent report. Furthermore, the areas under the curve (AUC) of parent-rated instruments reported modest to excellent validity. Based on the evidence, the developers of the CMRS chose to create a measure that relied mainly on parent report.

Other parent report measures have been used to screen for Paediatric Bipolar Disorder, but these measures were not developed to look specifically for mania. One such measure is the Child Behaviour Checklist (CBCL). The CBCL, in addition to providing markers of psychopathology, has been used to detect mania in children. However, on the CBCL, researchers saw a consistent pattern of elevated scores, especially on the following symptoms: aggressive behaviour, attention problems, delinquency, anxiety, and depression. This pattern may be due to the high comorbidity of ADHD, oppositional defiant disorder, conduct disorder, and anxiety disorders in children with paediatric Bipolar Disorder. And although the CBCL is a reliable and validated measure, low scores on the CBCL may only rule out mania – conversely, it would be erroneous to rule in mania using CBCL scores alone.

For these reasons, the CMRS was developed to accurately and reliably assess mania in paediatric Bipolar Disorder, and differentiate its symptoms from other disorders with high comorbidity with paediatric Bipolar Disorder.

Impact

Though there is no gold-standard screening tool for Paediatric Bipolar Disorder, the CMRS has been described as a promising and useful tool for such a purpose. For example, institutional protocols for diagnosing and evaluating Bipolar Disorder in children may use the CMRS as an initial screening tool to establish the need to further evaluation of mania symptoms. In addition, the parent version of the CMRS (the CMRS-P) has been used in research studies to detect changes in children’s mania symptoms due to pharmacotherapy or psychotherapy. The CMRS is the first measure specifically developed for the purpose of screening for Bipolar Disorder in children.[30] As such, it offers an alternative to broadband rating scales like the Child Behaviour Checklist, which has been used as a screening tool for Bipolar Disorder in children with mixed findings regarding its reliability.

Furthermore, the CMRS-P (both the brief and full versions) have shown to be effective in distinguishing between mania and ADHD. The brief version effectively retains characteristics of the original CMRS, allowing for wider application and longitudinal use. Psychometric studies of the CMRS has demonstrated that the measure has excellent reliability and validity. Internal consistency is excellent and the measure correlates with clinician-administered interview measures for diagnosing paediatric mania. The measure is also accurately able to differentiate symptoms of paediatric Bipolar Disorder from ADHD and healthy control groups more than 90% of the time. Furthermore, the use of the CMRS in pharmacological research suggests that this measure is sensitive to treatment over time, which means that you can use this measure to assess treatment effectiveness.

Limitations

The CMRS suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them – in this case, the parent or teacher – in a phenomenon called the social desirability bias. Like all questionnaires, the way the instrument is administered can also influence the final score. If a person is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey. The age of the youth also may matter. Although the Child Mania Rating Scale has been shown to be a valid and reliable measure of mania in children, one concern is that its validity might change as the youth becomes an adolescent, and parents or teachers have less influence and awareness about the youth’s behaviour outside of the home or school. Additionally, it is also unclear of the CMRS’s ability to assess the change in mania systems as a child cycles out of mania and into depression.

Use in Other Populations

While the CMRS has not been validated in other languages, the CBCL, YMRS, GBI, and KSADS all have. However, the CMRS has been tested and translated into Spanish. The CMRS is available in fourteen languages with back translation through native/bilingual speakers, though not tested in all languages.

What is the Altman Self-Rating Mania Scale?

Introduction

The Altman Self-Rating Mania Scale (ASRM) is a 5-item self-reported diagnostic scale which can be used to assess the presence and severity manic and hypomanic symptoms, most commonly in patients diagnosed with bipolar disorder.

Effectiveness

The ASRM scale has been shown to be an effective self-reported questionnaire for screening patients with acute mania as well as measuring anti-manic treatment effects. Though only a 5-question instrument, the scale’s compatibility with the clinician administered Young Mania Rating Scale and the DSM-IV criteria give substantial diagnostic power for such a brief instrument.

Format

The Altman Self-Rating Mania Scale assess differences in “normal” or baseline levels in five subjective and behavioural areas:

  • Positive mood.
  • Self-confidence.
  • Sleep patterns.
  • Speech patterns and amount.
  • Motor activity.

Each of these areas has five statements which correspond to scores 0 through 4; with 0 being unchanged from “normal” or baseline, to 4 being overtly manic thoughts or behaviour. The subject is asked to choose one statement from each of the five areas that best describes the way they have been feeling over the past week.

Scoring

Scores above a 5 are indicative of mania, or hypomania, with the severity of symptoms increasing with higher scores. Examining score changes over time is also used to determine the efficacy of a particular treatment in a clinical setting and to qualify whether the severity a manic episode is increasing or decreasing.

What is the Young Mania Rating Scale?

Introduction

The Young Mania Rating Scale (YMRS), developed by Vincent E Ziegler and popularised by Robert Young, is an eleven-item multiple choice diagnostic questionnaire which psychiatrists use to measure the presence and severity of mania and associated symptoms.

Background

The scale was originally developed for use in the evaluation of adult patients with bipolar disorder, but has since been adapted for use in paediatric patients. The scale is widely used by clinicians and researchers in the diagnosis, evaluation, and quantification of manic symptomology.

A similar scale was later developed to allow clinicians to interview parents about their children’s symptoms, in order to ascertain a better diagnosis of mania in children. This parent version (P-YMRS) can be completed by a parent or a teacher to determine whether a child should receive further evaluation from a psychologist or psychiatrist. Clinical studies have demonstrated the reliability and validity of the parent version of the scale, which has been found to provide “clinically meaningful information about mood disorders in youth.” The P-YMRS does succeed in identifying most cases of childhood bipolar disorder, but it has an extremely high false positive rate.

What is the Mood Disorder Questionnaire?

Introduction

The Mood Disorder Questionnaire (MDQ) is a self-report questionnaire designed to help detect bipolar disorder.

It focuses on symptoms of hypomania and mania, which are the mood states that separate bipolar disorders from other types of depression and mood disorder. It has 5 main questions, and the first question has 13 parts, for a total of 17 questions. The MDQ was originally tested with adults, but it also has been studied in adolescents ages 11 years and above. It takes approximately 5-10 minutes to complete. In 2006, a parent-report version was created to allow for assessment of bipolar symptoms in children or adolescents from a caregiver perspective, with the research looking at youths as young as 5 years old.

The MDQ has become one of the most widely studied and used questionnaires for bipolar disorder, and it has been translated into more than a dozen languages.

Development

The MDQ was developed as a screening tool for bipolar disorder, and assesses symptoms of mania and hypomania It was developed in the hopes that it would reduce the mis-diagnosis and delayed diagnosis of bipolar disorder. The first 13 items on the measure ask about any manic/hypomanic symptoms that may have occurred during one’s lifetime. These items are based on the DSM-IV criteria for bipolar disorder. Additional items then ask if these symptoms have happened during the same period of time (an “episode”), and how severely these symptoms affected functioning (assessing impairment).

In developing this tool, the MDQ was administered to a group of bipolar patients to assess feasibility and face validity, leading to revision of the items. Following this initial study, researchers have assessed psychometric properties of the MDQ, finding that the measure possesses adequate internal consistency. The measure has also demonstrated fair sensitivity in several studies, although sensitivity may be greater in inpatient versus community settings. First built for use in adults, it has been translated into many languages and tested in a range of different settings. Researchers also have studied whether parents could use this to provide useful information about their child or adolescent. Meta-analyses have found that the MDQ is one of the best self-report tools for assessing hypomania or mania in adults, and the parent report version is one of the three best options available for parents to use about their children.

Limitations

One limitation of the MDQ is that it has shown higher sensitivity when detecting bipolar I compared to other bipolar spectrum disorders. It is much less sensitive to bipolar II, often missing more than half of the cases with this diagnosis when using the recommended algorithm. Additionally, the sensitivity and specificity of the MDQ has been shown to differ by the use of a standard vs. modified cutoff (i.e. simplifies the cutoff to be based only on symptom endorsement, rather than impairment). Sensitivity and specificity of the MDQ also depend on study inclusion and exclusion criteria. Including more severe cases will increase the apparent sensitivity, because it is more likely that they will have high scores. Including healthy controls or people who are not seeking services will exaggerate the specificity of the test, as these individuals are unlikely to have manic symptoms and will score very low on the measure as a result.

Another major limitation of the MDQ is that it is not to be sensitive to treatment effects. It asks about lifetime history of symptoms, which is a strength for screening and detection, but a weakness for measuring the current severity of mood symptoms. The MDQ also uses a yes/no format for the symptoms, rather than asking about the severity of each. Other rating scales are more useful for measuring severity and treatment outcomes.

Additionally, self-report measures have some disadvantages, including bias that can stem from social desirability and demand characteristics.

What is the Bipolar Spectrum Diagnostic Scale?

Introduction

The Bipolar Spectrum Diagnostic Scale (BSDS) is a psychiatric screening rating scale for bipolar disorder.

Background

It was developed by Ronald Pies, and was later refined and tested by S. Nassir Ghaemi and colleagues. The BSDS arose from Pies’s experience as a psychopharmacology consultant, where he was frequently called on to manage cases of “treatment-resistant depression”. Patients are typically diagnosed during their 20s. The lifetime prevalence of BD is approximately 1%, rising to 4% if a broader definition of bipolar spectrum disorder is used.

The English version of the scale consists of 19 question items and two sections. It differs from most scales in that it does not list separate items, but rather presents a short paragraph talking about experiences that people with bipolar spectrum disorders often have. The person checks off which phrases or experiences fit them. Bipolar spectrum disorder includes bipolar I and bipolar II, and other cases not meeting criteria for those disorders.

The scale was validated in its original version and demonstrated high diagnostic sensitivity, meaning that most people with confirmed bipolar diagnoses scored high on the BSDS. The BSDS may do better than other scales at detecting types of bipolar disorder that do not involve a full manic episode, such as bipolar II or cyclothymic disorder.