The Child Bipolar Questionnaire (CBQ)

A Screening Instrument for Juvenile-onset

Bipolar Disorder
Demitri F. Papolos,M.D. Melissa Cockerham, and John Hennon, Ph.D

In order to address the significant gap in available psychiatric rating scale

instruments designed to assess juvenile-onset bipolar disorder symptoms,
the Juvenile Bipolar Research Foundation (JBRF) has supported the
development of an assessment instrument for this purpose. This scale,
called the Child Bipolar Questionnaire (CBQ), is a 65-item behavioral
assessment tool. Preliminary data indicate that the CBQ has adequate-to-
excellent test-retest and inter-rater reliability characteristics; that it is
internally consistent. The instrument is written in simple English (estimated
reading grade level = 8), and it may be used with either a parent/parent
substitute or a clinician as the assessor. Some preliminary work examining
utility and reliability of the instrument when self-administered is quite
promising (data to be published). A Spanish-language version is available.
Either alone or in combination with other psychiatric rating scales, the CBQ
may prove to be an effective screening tool for early-onset bipolar disorder.
Via the Internet-based data collection system of the JBRF,
www.bpchildresearch.org), we have assembled data germane to this issue.
The JBRF website data collection system has been fully operative since early
2003 and CBQ data, and other diagnostically-useful information have now
been assembled on several thousand children/adolescents. For a substantial
fraction of the children and adolescents for whom website accounts at the
JBRF website have been established, the parents/guardians report that there
has been a diagnosis of bipolar disorder previously assigned by a physician
(usually pediatrician or child psychiatrist) or other health professional.
The availability of JBRF’s large and growing database with information of
testable reliability on both psychiatric rating scale data and prior/current
bipolar disorder diagnostic status provides a potentially rich opportunity for
the development of a screening algorithm designed to identify
children/adolescents with a strong diathesis for, or early onset of, bipolar
disorder. Accordingly, we assembled CBQ data, and related parent-provided
history and current symptoms information via the JBRF’s Internet-based data
acquisition system.

Psychiatric Rating Scale Characteristics. The CBQ item data are obtained
as Likert scale data, with response range 1-4. For the purposes of the
analyses, we dichotomized these responses, with 1-2 recoded as zero and 3-4
recoded as 1. The CBQ instrument has an important subscale called the CBQ
Core Bipolar Symptoms Subscale, comprising 35 of the 65 CBQ items.
Scoring
Determination of a “probable” diagnosis of childhood-onset bipolar disorder is
based on positive endorsement of >40/65 general items at frequencies > 2,
or alternatively at least 20/33 core syndromal symptoms (see below).

Results
There were 827 subjects for whom both bipolar diagnostic and CBQ data
were obtained via the JBRF internet-based system. For 619 (74.8%) of
these subjects, it was reported that a diagnosis of bipolar disorder had
formally been assigned at some prior time by a clinician (pediatrician,
psychiatrist, or other clinician). Included in this group were 290 girls
(35.1%) and 537 boys; average age was 10.6 ± 3.6 years (range 2.2 – 20).

Receiver operating characteristic (ROC) analysis predicting BPD diagnostic

status from CBQ total score while adjusting for age and sex, and using a
75% prediction probability as a binary cutoff-point revealed effective
predictive capability for the CBQ instrument. With this cutoff, the positive
predictive value of the CBQ was 82.8%, with sensitivity = 62.8% and
specificity = 61.5%.

Among the CBQ items with the strongest correlations with BPD diagnosis are
several that have obvious face validity. For example, the three CBQ items
most strongly correlated with bipolar diagnostic status are: Item 62 “Has
acknowledged experiencing hallucinations,” Item 26 “Has many ideas at once,”
and Item 31 “Displays abrupt, rapid mood swings.” All of these have odds
ratios exceeding 2.0.

1.Papolos D, Cockerham M, Hennen, J. 2004. The Child Bipolar Questionnaire:

Preliminary reliability and validity data, submitted for publication, journal unspecified
in compliance with journal rules for authors.

2. The Development of The Child Bipolar Questionnaire V. 2.0 – A Diagnostic

Screening Inventory for Juvenile-onset Bipolar Disorder. Papolos,, D.& Tresker, S.
Pediatric Bipolar Disorder Conference –March, 2003, Washington, D.C.

3. Papolos, D.F., & Papolos, J.D. The Bipolar Child: The Definitive and Reassuring
Guide to One of Childhood's Most Misunderstood Disorders. Broadway Books, N.Y.,
December, 2002.
 The Bipolar Child Questionnaire Version 2.0
Core Syndromal Symptoms

4) is hyperactive and easily excited in the PM

5) has difficulty settling at night

6) had difficulty getting to sleep

10) craves sweet-tasting foods

24) is easily excitable

25) has periods of high, frenetic energy and motor activation

26) has many ideas at once

27) interrupts or intrudes on others

28) has periods of excessive and rapid speech

29) has exaggerated ideas about self or abilities

30) tells tall tales; embellishes or exaggerates

31) displays abrupt, rapid mood swings

32) has irritable mood states

33) has elated or silly, goofy, giddy mood states

34) Displays precocious sexual curiosity

36) takes excessive risks

43) fidgets with hands or feet

44) is intolerant of delays

45) relentlessly pursues own needs and is demanding of others

47) argues with adults

48) is bossy towards others

49) defies or refuses to comply with rules

50) blames others for his/her mistakes

51) is easily angered in response to limit setting

52) lies to avoid consequences of his/her actions

53) has protracted, explosive temper tantrums

 54) has difficulty maintaining friendships

55) displays aggressive behavior towards others

56) has destroyed property intentionally

57) curses viciously, uses foul language in anger

58) makes moderate threats to others or self

59) makes clear threats of violence to others or self

61) is fascinated with gore, blood, or violent imagery

This article appeared at the poster presentation of the NIMH sponsored

Pediatric Bipolar Disorder Conference – March, 2003
–Washington, D.C.

The Development of The Child Bipolar

Questionnaire V. 2.0 – A Diagnostic
Screening Inventory for Juvenile-onset
Bipolar Disorder
Demitri Papolos, M.D.1,2 and Steven Tresker, B.A.2
1
Program in Behavioral Genetics, Department of Psychiatry,
Albert Einstein College of Medicine, Bronx, N.Y.
2
The Juvenile Bipolar Research Foundation, Maplewood,
New Jersey http://www.jbrf.org
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 disorder (PBD) suggesting a developmentally different
presentation in young children as compared to its adult form (Carlson, 1984;
Faedda et al., 1995; Wozniak and Biederman; 1997Geller et al., 1998;
Papolos and Papolos, 1999; Biederman et al., 2000; Egeland et al.,2000).
Adult-onset and juvenile-onset forms of bipolar disorder (BPD) have certain
similar features and comorbidities in common, but in the juvenile form of the
disorder, the complexities wrought by the frequent overlap of symptoms with
other disorders that are 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 is an important task 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.

The Bipolar Child Parent Questionnaire Version 2.0 (CBQ V.2.0), a 65 item
questionnaire, has been developed to serve as a rapid screening inventory of
common behavioral symptoms, and temperamental features associated with
PBD. The first version of the CBQ, version 1.2, contained 85 items, many
drawn from DSM-IV categories of childhood psychiatric illnesses. This
inventory, as a first iteration, was constructed as a method to determine
rates of positively endorsed symptoms for specific age epochs, and scored
retrospectively by parents of children diagnosed with PBD by DSM-IV criteria.
The most common positively endorsed symptoms were rank ordered
according to frequency of occurrence (scores > 60%), and of these, the 65
highest ranked symptoms and behaviors were included in the CBQ Version
2.0.

Survey and Child Bipolar Parent Questionnaire Instrument (CBQ)

This CBQ 1.2 inventory was administered along with a survey that consisted
of 35 questions that assessed demographics, premorbid symptoms and
behaviors, family psychiatric and substance abuse history, treatment
response, as well as an 85 item checklist that recorded parents retrospective
reports of symptoms and behaviors in chronological two- year age epochs
from birth to age 20. 70 of 85 items from the behavioral checklist were
drawn from the DSM-IV diagnostic categories for childhood and adult
psychiatric disorders that define criteria for: separation anxiety disorder,
generalized anxiety disorder, phobias, obsessive compulsive disorder,
oppositional defiant disorder, conduct disorder, attention-deficit disorder,
major depression and bipolar disorder. Additionally, because several clinical
studies reported on juvenile-onset cases (Papolos et. al. 1996; Wozniack et
al, 1995; Geller et al,1998;) have found a predominance of rapid and ultra-
ultra rapid cycling variants, the frequency of mood cycles was evaluated by
additional items which asked parents to rate mood variations occurring at
hourly intervals (one and six hours and greater than six hours were
included), as well as through a visual display illustrating six different possible
cycling patterns. Follow-up telephone interviews were conducted with parents
to validate and enlarge upon the survey responses.

Demographic and Phenomenological Characteristics

The sample comprised all children and adolescents (n=210), ages 5.4-18.8
yrs., consecutively referred over a 36 month period (11/1999 - 11/2002) to
the practice of one of the authors (DFP). The mean age 10.2 yrs. 61.6%
were male Each diagnostic evaluation involved separate interviews with
children and one or both parents. For every diagnosis, information was
gathered regarding ages of onset and offset, number of episodes and
treatment history. A full 82.9% of the sample had some psychiatric
symptoms by 6 years of age, 79% at or prior to the age of 4, and 54% by
age 2 or earlier. 52.1% had been seen at least once by a mental health
professional by the age of 5, 88% by age 11, and almost the entire sample
(99.1%) by age 16. 72% of the sample was diagnosed with bipolar disorder
– NOS, 15% with BP I and 13% BP II. 86.3% had at least one previous
DSM-IV diagnosis.

Diagnostic Criteria

To be given a lifetime diagnosis of mania, the child had to meet full DSM-IV
criteria for a manic episode with associated impairment. Thus a child must
have met criteria A for a period of extreme and persistently elevated or
irritable mood, plus criteria B; manifested by three (four if mood is irritable
only) of seven symptoms during the period of mood disturbance. To be
diagnosed with BP-NOS the child must have had distinct periods of
abnormally, elevated, expansive or irritable mood, most of the day, nearly
every day for repeated periods (a minimum of 5 such episodes) for at least 2
days as indicated by either subjective report or observations made by others,
and during the period of mood disturbance have 3 or more of the following
symptoms present to a significant degree (4 if the mood is only irritable);
inflated self esteem or grandiosity, decreased need for sleep, more talkative
than usual or pressure to keep talking, flight of ideas or subjective
experience that thoughts are racing, distractibility, increase in goal-directed
activity or psychomotor agitation, excessive involvement in pleasurable
activities that have a high potential for painful consequences.

In the BP-NOS group, marked variations in mood and energy were present
and were characterized by abrupt, rapidly alternating levels of excitability,
emotional lability, and motor activity. A large majority of cases experienced
chronic irritable mood states with a superimposed diurnal pattern of irritable
mood states in the morning on arising, associated with decreased energy and
low activity, followed by intense, rapid shifts of mood throughout the day
with intensification in the PM of irritable or elated/euphoric (silly, goofy,
giddy) mood states, as well as, early insomnia, and middle of the night
arousals. A majority of cases exhibited a low tolerance for frustration in
situations that required sustained attention, interest and effort which was
manifest by difficulties with postponement of immediate gratification, such as
waiting one’s turn, or denial of expressed needs, as well as, changes in
planned activities, established routines, or making required transitions from
one context to another. This deficit, combined with poorly regulated
attentional focus, often resulted in maladaptive responses, such as seeming
not to listen, interrupting or intruding on others, and disruptive,
oppositional/defiant, and provocative behaviors, or -- in the extreme --
temper tantrums and aggressive rage attacks, often followed by sullen
withdrawal and expressions of remorse. Episodes of anger dyscontrol, temper
tantrums, rages, often of more than half an hour in duration, occurred
spontaneously, but were most often precipitated by limit setting attempts by
parents or other authority figures, and were commonly associated with the
use of profane language and/or the expression of physical violence. The
typology of rapid cycling of fast frequency in these patients was of the type
described by Kramlinger and Post (1995), who performed extended in-
patient psychiatric evaluations that included longitudinal assessments,
retrospective life charting and prospective assessment of daily mood by self
and blinded observer ratings to describe this variant of the condition in
adults.

Results

We describe the development of this inventory, and the development of a

validation study that will use a newly developed companion diagnostic
interview schedule to be conducted in a group of 100 children with BPD by
diagnosed DSM-IV criteria, 50 control children with no psychiatric diagnoses,
and 50 subjects with attention-deficit disorder with hyperactivity. 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, for 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.

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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