A decision-making framework is adapted from evidence-based medicine to guide assessment sequences in a patient-centered approach. Emphasis is placed on approaches that currently have the best validity and are feasible in most clinical practice settings. Hess methods increase accuracy and address many controversies surrounding pediatric bipolar diagnoses. A result, practitioners have had minimal training in the assessment of PAD. Should busy clinicians invest the time and effort to learn about evidence-based assessment treatises for pediatric bipolar disorder? Given the stakes involved in making this diagnosis correctly, as well as the rapid advances in the evidence base over the last several years, there are few niches that could provide so substantial a return on investment.
Other papers in this special issue review the distinction between PAD and other forms of mood desegregation and aggression (1 , 2) and the evidence for the validity of PAD as distinct from ADD, depression, or other more common developmental psychopathology (3). This review will address key topics, such as why o assess for PAD, when it is clinically indicated, how to change assessment strategies to match the individual needs of the patient over the course of treatment, and what promising future directions might be worth adding to clinical practices in the future. Why Add formal AssessmenT procedures FRR Pad -or The Clinical OUTBOX?
Conventional wisdom was that bipolar disorder most often manifested during young adolescence, pediatric bipolar disorder (PAD) was considered exotic, and it was not part of the core training for physicians or mental health professionals working with youths. Even now, most textbooks and training materials focus on bipolar disorder as an “adult” condition. As The place where PAD seems most scarce is in textbooks. There are now several thousand peer reviewed articles describing and validating pediatric bipolar disorder, drawn from dozens of independent research groups around the world (4).
A recent meta-analysis of epidemiological studies found that ?2% of children and adolescents in the community – not clinics – meet criteria for bipolar spectrum diagnoses (5), with equal rates in the U. S. A. Versus the rest of the world. A Canadian study published after the meta-analysis replicated the 2% fugue (6). Increased rates of clinical diagnoses started from a baseline of almost never diagnosing PAD (7), and clinical and epidemiological rates are now converging. Where have these bipolar cases been hiding?
If the energy and attention problems are salient, then the likely diagnosis is ADD or ODD, particularly in Europe and Israel, whereas aggression is more likely to attract a conduct disorder label, and psychosis a schizophrenia diagnosis – especially in ethnic minorities in the U. S. A (17). Because bipolar is an episodic illness, with dramatically different presentations during different phases, it is exceptionally challenging for clinicians to develop a good prototype for the “typical” case.
Prototype matching is a main way that experienced clinicians formulate cases (18), but it performs badly with PAD (19, 20). Vignette studies demonstrate tremendous range of opinion, often varying by global region, when clinicians examine cases with potential PAD (21, 22). Clinical PAD diagnoses rarely agree with each other or with structured interview results at better Han chance rates (23), contributing to the long lag between onset of problems and diagnosis in youths (24) and adults (25, 26).
Diagnostic disagreement is less surprising considering the dearth of formal training about PAD, forcing practitioners to learn as they work. Using evidence-based assessment tools can help close the gap, especially if practitioners can easily incorporate the methods without additional time, having published validity data. The challenges now are choosing the best from among contenders, and understanding each tool’s role at different stages of assessment and treatment. When is ASSeSSmenT of pad CliniCAlly indicated? Index of Suspicion” (28, 29).
Figure 1 illustrates how diagnostic probability maps onto clinical actions. IBM refers to two major choice points along this continuum: The Wait-Test Threshold, and the Test-Treatment Threshold (27). Below the Wait-Test Threshold, a diagnosis is considered “ruled out. ” Above the Test-Treatment Threshold, a diagnosis is considered firm enough to begin treatment. Between the two thresholds is where additional assessment is needed to either push the arability below the Wait-Test or above the Test-Treatment Threshold.
IBM does not attach specific numbers to these thresholds. Where to set the bar is a clinical judgment, depending on risks and benefits. Formal approaches for integrating these utilities into decision-making may gain popularity as technology reduces the inconvenience associated with computation (27, 30). Table 1 lists steps in evidence- based assessment of PAD detailed below. Step 1. Know the base rate of PAD in your setting. The first piece of evidence to incorporate in fast, frugal PAD assessment s its base rate in a clinical setting.
PAD rates vary widely depending on where one works. PAD is rare in the general community, but somewhat more common in outpatient practices, and even more in practices that specialize in mood disorders. Table 2 lists benchmarks from different settings. In many settings, PAD rates will fall below the clinician’s Wittiest threshold. For example, if a clinician decides that conditions seen in fewer than 1 in 20 cases do not warrant extra assessment unless other warning signs are evident, then their Wait-Test threshold is 5%. If working where