A New Study by Gabrielle Carlson, MD, and Joseph Blader, PhD, Reveals Implications for Diagnosis When Informants Agree or Disagree about Manic Symptoms

In a special edition of the Journal of Child and Adolescent Psychopharmacology Stony Brook University Professor Gabrielle Carlson, MD, and Assistant Professor Joseph Blader, PhD, discussed the implications for diagnosis when parents and teachers agree or disagree in their reports of manic symptoms among children and adolescents referred for outpatient psychiatric evaluation.

Their study is important because bipolar disorder/mania in children and adolescents is a serious disorder and there is some controversy about how to diagnose it.  Consistent with previous studies examining parent/teacher agreement regarding behavioral and emotional disorders, the researchers found only a moderate correlation (r=0.27) in the ratings of manic symptoms on the Child Mania Rating Scale completed by parents and teachers of 911 clinically referred children aged 5 through 18. The investigators examined the differences in carefully made clinical diagnoses when manic symptoms were observed by both parents and teachers—that is, when there was agreement between parent and teacher ratings—and when they were observed only by parents and not by teachers—that is, when there was disagreement.

Drs. Carlson and Blader selected the top quartile of parent and teacher ratings to define agreement, and the top quartile of parent and bottom quartile of teacher ratings to define disagreement.  All children in the study were diagnosed by four highly skilled members of the Department of Psychiatry faculty after 3-hour interviews with the children and parents and a review of school records, symptom checklists and other pertinent information. As expected, children whose parents rated their manic symptoms in the highest quartile were more likely to be diagnosed with bipolar disorder than those in the lower quartiles (14.7% versus 4.4%). The agreement or disagreement of teachers’ ratings did not affect the likelihood that the children would be diagnosed with bipolar disorder.

More significantly, Drs. Carlson and Blader found that when there was agreement between parents and teachers on high mania symptom ratings, the children were ten times more likely to be diagnosed with something other than mania, that is, an externalizing disorder—attention deficit hyperactivity disorder, oppositional defiant disorder or conduct disorder.  Because these conditions are much more common than bipolar disorder, they are more likely to provide a better explanation of the manic symptoms rated by parents and teachers.

When parents observed manic symptoms but teachers reported very low rates, the children were more likely to be diagnosed with internalizing disorders such as anxiety and depressive disorders.  They do not have a rapid-cycling form of bipolar disorder where mania occurs only at home, but another type of mood disorder which requires a different treatment from mania.   

The authors conclude that in addition to collecting ratings of manic symptoms alone, it is important to obtain multiple sources of information to make a diagnosis and to discern whether mania and manic symptoms are occurring in episodes that are different from the child's usual self.
Dr. Carlson and Eric Youngstrom, PhD, Professor of Psychology and Psychiatry at the University of North Carolina at Chapel Hill, co-edited the special October 2011 edition of the journal which was devoted to the diagnostic implications of information variance. Dr. Carlson is the Director of Child and Adolescent Psychiatry at Stony Brook University. Dr. Blader is an Assistant Professor in the Department of Psychiatry and Behavioral Science, who conducts scientific research about psychiatric disorders in children and adolescents.