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Mania or ADHD: Assessment with CBCL

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Differentiating Mania from ADHD in Prepubertal Children Using the Child Behavior Checklist

Augusta Czysz

Penn State College of Medicine

2002

Background:

Child Behavior Checklists (CBCL) were first published in 1978 and 1979 by Achenbach and Edelbrock. They consist of lists of 118 problem behaviors that are organized into the Internalizing scale, including anxious obsessive behaviors, somatic complaints, schizoid behaviors and depressed withdrawal behaviors; the Mixed scale, comprised of immature-hyperactive behaviors; and the Externalizing scale, which includes delinquent, aggressive and cruel behaviors. A normalized T score was assigned to each behavior using a representative sample of age-appropriate children. These scores are tallied to give a child’s behavioral profile. These profiles were found to aid in differentiation of certain problem behaviors and syndromes. The original CBCL can be found as follows. Achenbach, TM. Edelbrock, CS. The Child Behavior Profile. J Consult Clin Psychol. 46, 478-488. 1978. 47, 223-233. 1979.

Identifying Bipolar Disorder for Early Intervention:

· Spencer, TJ. Biederman, J. Wozniak, J. Faraone, SV. Wilens, TE. Mick, E. Parsing pediatric bipolar disorder from its associated comorbidity with the disruptive behavior disorders. Biol Psych. 49(12): 1062-1070. 2001.

According to a review article by Spencer et al, children with ADHD are 10x as likely to develop bipolar disorder (BD) than age-matched and gender-matched controls so it is important to be able to identify and begin treating BD early to help prevent unnecessary social and functional impairment for the child.

Diagnosing prepubertal Bipolar Disorder vs ADHD:

1. Geller, B. Williams, M. Zimerman, B. Frazier, J. Beringer, L. Warner, KL. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affective Disorders. 51(2): 81-91. 1998.

Geller et al found that, as compared to adolescent and adult onset BD, mania in prepubertal children can be non-episodic in nature, have less sleep disturbance than in adults, and have the possibility of a rapid (4 or more episodes/yr), an ultra-rapid (a few days to a few weeks duration of episode) or ultradian cycle (episodes varying in a 24-h pd) (83.3%). Mania was defined as grandiosity, elated mood, daredevil acts, uninhibited people seeking, silliness and laughing, flight of ideas, racing thoughts, hypersexuality, decreased need for sleep, sharpened thinking, increased goal-directed activity, increased productivity, accelerated speech, hyperenergetic state and distractibility. Geller et al found that bipolar (BP) children have a significantly higher occurrence rate of all symptoms of mania except hyperenergetic states and distractibility. For example, elated mood in BP pts occurred 86.7% of the time while the ADHD pts had it 5.0% of the time. Similarly, grandiosity occurred 85.0% of the time with BD subjects as opposed to 6.7% of the time in ADHD. They noted that bipolar children would often also have grandiose delusions (55.0% BP group) and psychosis (60.0%). Based on these data, primarily gathered through the WASH-U-KSADS, Geller et al concluded that it is possible to diagnose prepubertal BD with comorbid ADHD.

2. Geller, B. Warner, K. Williams, M. Zimerman, B. Prepubertal and young adolescent bipolarity versus ADHD: assessment and validity using the WASH-U-KSADS, CBCL and TRF. J Affective Disorders. 51(2): 93-100. 1998. (referred to as addendum)

CBCL and Teacher Report Form (TRF) scores allowed for differentiation between BPD and ADHD based primarily on "non-specific externalizing dimensions (e.g., hyperactivity, aggressivity)" while the WASH-U-KSADS provided “clinically relevant differentiation by categorical mania-specific criteria (e.g., elated mood, grandiosity, racing thought).”

3. Hazell. Lewin. Carr. Confirmation that Child Behavior Checklist clinical scales discriminate juvenile mania from attention deficit hyperactivity disorder. J Paed & Child Health. 35(2): 199. 1999.

Hazell et al conducted a study to further support that CBCL scales could differentiate mania from ADHD in juveniles. Experienced clinicians administered CBCL to 9-13 year-old boys and their mothers and compared the results to the WASH-U-KSADS. The study groups were divided into mania with ADHD, ADHD without mania and no diagnosis of ADHD, mood, psychotic, anxiety or conduct disorder. A parent, usually the mother, completed CBCL and the child’s classroom teacher completed TRF. They did not show substantial differences between the combined mania-ADHD group and the ADHD alone group based on the TRF. No parental biases were found to explain why CBCL scores were valid but TRF scores did not demonstrate a difference between mania with ADHD and ADHD alone. Limitations included the diagnosis of mania being made if either the child or the parent report described mania. There were few cases where mania was indicated on both the child’s and the parent’s report. The sample was a convenience sample so it may not be accurate. Another question regarding this study is if the CBCL would be as useful in diagnosing mania unaccompanied by ADHD since none of the patients in this study met that description. Overall, however, the study did support the use of the CBCL in differentiating combined mania and ADHD from ADHD alone.

Summary:

According these studies, the CBCL is an effective way to differentiate between mania and ADHD in prepubertal children. They can be especially helpful in the outpatient setting.

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