In the hundreds of child psychiatric research studies published on bipolar disorder in children since 1995, the studies using research diagnostic interviews of parents and children to establish the diagnosis routinely reported the name of the interview used to establish the diagnosis. These diagnostic interview names are well known to child psychiatrists and served as a testament to the accuracy (reliability and validity) of the diagnosis and the care with which the interviews were done. The named research interviews suggested rigor and attention to detail beyond what might be found in a more informal routine clinical interview. The large number of competing views about the appearance of bipolar disorder in children and the increasing disillusionment about the existence of the disorder in childhood began to raise suspicions about the ability of these research interviews to insure an accurate diagnosis of the disorder in children and adolescents.
In the June, 2012 issue of the prestigious Journal of the American Academy of Child and Adolescent Psychiatry, Cathryn Galanter, M.D. and colleagues in an article entitled, “Variability Among Research Diagnostic Interview Instruments in the Application of DSM-IV-TR Criteria for Pediatric Bipolar Disorder” give numerous detailed shortcomings of these research interviews for the diagnosis of pediatric bipolar disorder (Vol 51 Num 6, pp 5605-5621). The authors reviewed the written criteria for manic episode of the DSM-IV-TR and the written instructions and questions of six different leading research interviews. They did not observe researchers giving the interviews to research subjects. To understand the gist of the criticisms, it is helpful to appreciate the DSM-IV-TR criteria for a Manic episode listed below (DSM-IV-TR of the American Psychiatric Association, 2000, p. 362).
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a Mixed Episode
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
To merit the diagnosis of bipolar disorder, it is necessary to meet the criteria for manic episode above as well as other criteria. Much of the disagreement about the diagnosis in children was fought over the meaning of the criteria for manic episode and the diagnostic research interviews added to the ambiguity. It is necessary to meet the A criterion and only three of the B criteria if the A criterion were expansive or elevated mood. If the A criterion was irritable mood, four B Criteria had to be met to earn the diagnosis of manic episode.
Some of the problems with the interviews and the text describing the criteria in DSM-IV-TR discussed in the article are listed below:
1. Not all interviews require assessment of children as well as interviews with parents.
2. In interviews in which both parents and children are assessed, there was ambiguity about whether they should be interviewed separately or together . Further there was ambiguity about how information from the parents and children should be combined or weighted.
3. There was ambiguity about how to define the initial onset of bipolar disorder in children.
4. There was a lack of agreement between interviews about the coding of patients on criterion A. An example is the clinical scenario wherein a child has expansive and elevated mood for three days followed immediately by four days of irritable mood. Would this count for the seven days of mood disturbance for Criterion A and if so, would it count as irritable mood (requiring 4 additional B symptoms) or elevated/expansive mood (requiring 3 additional B symptoms). The instruments handle this issue differently.
5. The mood in the A criterion is required to be distinctly different from the patient’s usual functioning. In some interviews there was ambiguity about whether the B items were required to differ from the patient’s usual state as well.
6. It was not clear on some interviews whether A and B criteria were required to change simultaneously for the diagnosis of a manic episode or whether the A criteria could change at one point and the B criteria could change at another and the criteria for a manic episode would still be met.
7. Ambiguity about which mood episode to count for the diagnosis was an issue. Some interviews counted only the most severe mood episode regardless of when it occurred in relation to the research interview. Other interviews counted mood episodes in the past three months and still another counted only mood episodes in the month prior to the interview.
8. While some interviews rated irritable mood in the mania section of the interview, other interviews only rated irritability in other sections of the interview such as the depression section. Interviewers were still required to come to conclusions about the presence of irritability in the manic episode.
9. Some interviews known as semistructured interviews give suggested questions to ask the subject and allow for the interviewer to develop his or her own follow up questions based on the patient’s reply. This type of interview requires a highly trained professional to administer the interview. At some research centers, lay interviewers (non-professionals) were giving the semistructured interviews, but the interviews were subsequently “reviewed” by professionals. It is not clear that a professional review of a lay interview is an adequate substitute for an interview by a professional.
10. There is wide variation in the amount of training provided to interviewers.
Looking beyond the technical details of the interview instruments, the authors wisely note, ”…if clinicians come to an interview with a pre-conceived notion of a subject’s diagnoses, they may inadvertently collect information that confirms these diagnoses while ignoring disconfirmatory data”(p. 616). The article makes clear how the very tools designed to assure scientific excellence actually through their flaws contributed to the incorrect diagnosis of bipolar disorder in children.
Copyright Stuart L. Kaplan, M.D., 2012. Stuart L. Kaplan, M.D. is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis, available at www.amazon.com.