The Diagnostic Instruments

The Challenge

While there is continuing debate over the validity of the diagnosis of mania in children, a number of systematic clinical investigations and family/genetic studies have begun to shed light on the presentation and naturalistic course of pediatric bipolar (PBD), suggesting a developmentally different presentation in young children as compared to its adult form (Carlson, 1984; Faedda et al., 1995; Wozniak and Biederman, 1997; Geller et al., 1998; Papolos and Papolos, 1999; Biederman et al., 2000; Egeland et al.,2000). Adult-onset and juvenile-onset forms of bipolar disorder have certain similar features and comorbidities in common, but in the juvenile form of the disorder, the frequent overlap of symptoms with other disorders far more commonly diagnosed in childhood has had a confounding affect on clinical diagnostic practice for years (Papolos, 2002).

The development of specific diagnostic criteria that more closely resemble the actual presentation of symptoms and behaviors in childhood, as well as clinical tools to assist clinicians in the rapid and reliable assessment of children at risk, are important tasks for clinical research in the upcoming years. Additionally, genetic studies will benefit from the development of well validated, and rapid screening instruments for the large-scale ascertainment of affected sibling pairs that will be required to generate meaningful conclusions when candidate gene and genome wide searches are undertaken in this population. Toward that end, the Juvenile Bipolar Research Foundation has sponsoredthedevelopmentofacomprehensiveandintegratedsetofdiagnostictools. TheChildBipolarParent Questionnaire (CBQ) (Papolos and Papolos, 2002) is the foundation of this assessment package.

The Development of The Child Bipolar Parent Questionnaire Version 2.0 (CBQ)

The Child Bipolar Parent Questionnaire Version 2.0 (CBQ), a 65 item questionnaire rated on a Likert-type scale for frequency of occurrence, was developed by Dr. Demitri Papolos to serve as a rapid screening inventory of common behavioral symptoms and temperamental features associated with pediatric bipolar disorder. The CBQ measures, in a standardized format, the behavioral problems of children ages 5-17, as reported by their parents or parent surrogates.

The first version of the CBQ, an 85-item checklist, was constructed based on the model proposed by Depue et al. (1981) who derived a dimensional approach to defining bipolar disorder in adults. 70 of the original 85 items were keyed to symptoms drawn from DSM-IV diagnostic categories for separation anxiety disorder, generalized anxiety disorder, phobias, obsessive compulsive disorder, oppositional defiant disorder, conduct disorder, attention-deficit disorder, major depression and bipolar disorder. The checklist was administered to parents of a large clinical sample of children with a DSM-IV diagnosis of bipolar disorder. The most common positively endorsed items were rank ordered according to frequency of occurrence, and of these, the 65 highest ranked symptoms and behaviors were included in the CBQ Version 2.0. This initial research, suggesting a Core Phenotype for pediatric bipolar disorder involving dimensions of anxiety, attention deficit, and aggressive behavior, became the basis for the Core Diagnostic Criteria developed for a series of studies sponsored by The Juvenile Bipolar Research Foundation, and became the basis for several newly developed diagnostic companion interviews of the CBQ.

The Diagnostic Assessment Package – Child Bipolar Questionnaire (CBQ), Jeanne/Jeffrey Questionnaire for Children, and Child Bipolar Screening Interview (CBSI)

The Diagnostic Assessment Package was designed for use in clinical and research settings to screen for bipolar disorder in children from both parent and child report. The package includes two easy-to-use self-administered questionnaires – one for parents and one for children – and a follow-up interview to be administered by a clinician or researcher. The Core Diagnostic Assessment Package is available in hard copy or online version with downloadable data and summary report features.

Parent Self-administered Questionnaire – The Child Bipolar Questionnaire

The CBQ is a parent- report questionnaire designed for initial screening purposes. The questionnaire is suitable for use by clinicians and by research studies. The CBQ is available in paper-and-pencil and online versions. Items are rated “1-Never or hardly ever,” “2-Sometimes,” “3-Often,” or “4-Very often or almost constantly.” The questionnaire takes approximately 10 minutes to complete. The CBQ has 10 subscales, each of which may be scored separately.

Three scores may be derived from CBQ responses: a total score, derived from the number of items scored >1; a severity score, derived from the number of items scored >2; and a Core Criteria score, derived from a subset of 33 items keyed to Core Diagnostic Criteria.

Child Self-administered or Clinician Administered Questionnaire – The Jeanne/ Jeffrey Interview for Children

The child-report version of the CBQ is also for use by clinicians and research studies as an initial screening instrument. It was developed based on a model used by Martinez and Richters, 1993, in a community violence project. Keyed to CBQ items, the questions describe symptoms and behaviors experienced by another child, Jeffrey or Jeannie. Each item is illustrated with pictures designed to allow a child to endorse a symptom or behavior without the use of words. The scale was developed for use with children under 12 years old. It takes 15 minutes for a child to complete. The child responds by choosing a rating on an illustrated Likert-type scale that best matches the degree and frequency with which he/she has had the experience described. The scale is scored in the same manner as the CBQ. The Jeffrey/Jeannie includes many of the subjective symptoms of bipolar disorder and major depression that parents may not observe, including psychotic features. The current schedule is meant as a clinician administered interview. However, an online, interactive version of the Jeffrey/Jeannie which may be self-administered is in development.

Clinician Administered Interview -The Child Bipolar Screening Interview(CBSI)

The CBSI is a clinician- or researcher-administered interview. Developed as a follow-up to the CBQ and Jeffrey/Jeannie, it was designed to collect more detailed information about mood disturbance and accompanying mood-related symptoms from parents whose children were high-scorers on the self-administered questionnaires. The CBSI grew from the perceived need for an instrument covering all of the research criteria proposed for alternative phenotypes to DSM-IV (Narrow and Broad as well as Core phenotypes). The CBSI does not require specific episode duration or a specific type of mood episode to make a diagnosis. Rather, it gathers enough information about type and quality of mood states, periodicity and frequency of mood symptoms, clustering of symptoms, cycling, and occurrence across multiple settings, as well as other features associated with pediatric bipolar disorder, to diagnose using several different criteria sets, making it useful to studies interested in the comparative value of different phenotypes. It also provides information indicative of potential comorbidity, although insufficient to make DSM-IV diagnoses. The CBSI is simple to administer. Most of the items are rated on a Likert-type scale for severity, frequency, or duration of occurrence, in an effort to avoid the necessity of lengthy, descriptive responses from parents already overburdened with the demands of family life. This feature and the absence of rule-outs based on previously accepted definitions of an episode, make the CBSI appropriate for administration by non-psychiatrically trained personnel. An online version of the CBSI has been developed with the ability to download interviewer notes and tentative diagnoses as well as client/subject data.


Cronbach [alpha] coefficients were calculated to evaluate the internal consistency of the CBQ subscales and total score. The alpha estimate for the CBQ total score was 0.936 (95%CI 0.932 – 0.940). The corresponding alpha coefficient estimate among the 33 CBQ items forming the CBQ Core Criteria was very close to the alpha coefficient for the entire CBQ scale: 0.924 (95%CI 0.920 – 0.929). Of note, the alpha coefficient estimated among the 11 CBQ factors was substantially smaller (as expected), with alpha and its 95%CI estimated as 0.838 (95%CI 0.830 – 0.846). In the test-retest procedure, parents of 108 subjects were asked to repeat the CBQ assessments oftheirchildren/adolescentswithin7daysoftheinitialassessment. Theconcordancecoefficientestimateforthe CBQ total score was 0.819 (95%CI 0.757 – 0.881). The concordance coefficient for the CBQ core subscale score 0.786 (95%CI 0.714 – 0.858), and the concordance coefficients for the 11 CBQ factors ranged from 0.683 (Factor 7 [anergia/depression]) to 0.831 (Factor 4 [low threshold for arousal]). After further validation in a larger sample, the CBQ V. 2.0 may provide a useful screening instrument that can be used by pediatricians, and mental health practitioners, as well as by family genetic and offspring studies. We want to assess the ability of this instrument to satisfy three prerequisites for use in such clinical and research settings: (1) identification of core symptom categories related to bipolar disorder (2) use with children and young adolescents, and (3) ability to distinguish between affected and well siblings and control subjects with attention-deficit disorder with hyperactivity.


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