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As A Diagnostic Tool
Screening Utility
In order to address a significant gap in available screening instruments designed to assess pediatric bipolar disorder, the Juvenile Bipolar Research Foundation supported the development of the Child Bipolar Questionnaire (CBQ) and its companion piece; the Jeannie and Jeffrey Illustrated Interview for Children (J/J). The CBQ (and the J/J) measures the presence of the 65 symptoms that most frequently occur in children who are at risk for, or who have received a diagnosis of, bipolar disorder.
The symptoms are culled from the Diagnostic and Statistical Manual for Mental Disorders IV (DSM IV) criteria for mania, major depression, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, oppositional defiant disorder, conduct disorder and attention deficit disorder. This broad examination reflects the recommendations of a 2001 National Institute of Mental Health committee to explore the behavioral dimensions of these children who are so often troubled by a slew of co-occurring conditions.
Algorithms developed in conjunction with the CBQ can identify 1.) possible cases of bipolar disorder (BD) as defined by DSM IV, 2.) possible cases of BD with or without co-occurring Attention Deficit Hyperactivity Disorder (ADHD) and possible cases of ADHD with no mood disorder.
Additional algorithms can identify subjects who meet various proposed definitions of the disorder. Amongst those are the Core phenotype and the Fear-of-Harm (FOH) phenotype; subtypes of the illness as defined by research conducted by our Consortium of investigators. These phenotypes are based on a highly heritable trait found in a subgroup of children with the disorder. Research has determined that the FOH phenotype represents the children with bipolar disorder who suffer the most severe form of the illness in terms of both symptoms and course-of-life challenges. (Links to descriptions of these phenotypes are at the end of this section.)
Each algorithm has demonstrated excellent reliability and validity in psychometric testing in identifying its designated population.
Review the validation study of the Child Bipolar Questionnaire
Currently, K-SADS (Schedule for Affective Disorders and Schizophrenia for School Age Children) is the gold standard by which a diagnosis of bipolar disorder, ADHD and “no disorder” is made. However, the cost and time commitment required to administer K-SADS limits its utility in large studies and presents an obstacle for widespread, accessible screening. Further, K-SADS cannot identify the Core phenotype or the FOH phenotype.
The CBQ presents an acceptable option to K-SADS as a preliminary screening tool. The scoring algorithm for the Core Index, which is a subscale of 22 symptoms from the CBQ that represents the Core phenotype, proved to have excellent agreement with K-SADS for being able to differentiate between ADHD and a bipolar disorder. It demonstrated 100% agreement with K-SADS in differentiating between bipolar disorder and no disorder. Further, the CBQ can identify, with 96% accuracy, the presence of the FOH phenotype.
Plainly, the CBQ provides a reliable and much needed resource in screening for various definitions of pediatric bipolar disorder. The lack of clear guidelines and the confusing presentation of this complex illness often result in misdiagnosis and the initiation of medication that can worsen its condition. Of course its findings cannot substitute for the in-depth analysis of K-SADS or for a well-considered professional evaluation. But within the health sectors, awareness of the CBQ’S utility is rapidly increasing. And as primary care physicians find themselves assuming greater mental health responsibilities, a tool such as the CBQ is needed more than ever. The CBQ’s ease of use, accessibility, low cost and reliability make it an effective preliminary screening tool.
The CBQ’s Companion
The CBQ has a pediatric companion instrument; the Jeannie and Jeffrey Illustrated Interview for Children ages 5-12 (J/J). It is the first assessment tool for bipolar disorder designed specifically for children. With its comicip style pictures it engages the child’s interest and diminishes the threat of self-disclosure, allowing the child to reveal mood states, fears, suicidal thoughts, and/or hallucinations that he or she may be afraid to talk about with the parent and clinician. The completed instrument provides the psychiatrist, therapist, and parents insight into a child’s internal world so that he or she feels less isolated and alone. Moreover, medical and therapeutic interventions can be tailored to each child’s concerns and subjective feelings, as well as to his or her behaviors.
Keyed to the CBQ items, the questions of the J/J describe symptoms and behaviors experienced by another child, Jeannie or Jeffrey. 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.
See a sample page of the Jeannie Illustrated Interview
See a sample page of the Jeffrey Illustrated Interview
Implementation of the Instruments
The intended subjects of the questionnaires are children ages 5-17. The questionnaires are self administered and reported by the parents/surrogates and the child. Subjects rate the 65 items according to a Likert Scale for frequency of occurrence: 1=Never or hardly ever, 2=Sometimes, 3=Often, or 4=Very often or almost constantly. Online and hard copy versions are available and require about 20 minutes to complete. Both instruments are suitable for clinical and research purposes.
The online versions are currently offered through the JBRF website. The public is provided with free access to both instruments which they can then print out and bring to their clinician. For a modest fee, the consumer can elect to have the CBQ and/or the J/J scored automatically (described below).
The professional community can access the instruments through the Diagnostic Assessment Program by establishing a Clinician’s Pathway Account. This program provides the clinician with access to the instruments, reports of the diagnostic algorithms, automatic scoring and various capabilities to manage patient accounts. Within a year and a half of its launch, over 500 clinicians and 5 major centers have signed on to this program. (To sign up for this account, navigate to Clinician’s Pathway Access; Establish a Clinician’s Pathway Account.)
See a sample page of the Child Bipolar Questionnaire
Automatic Scoring of the CBQ will report:
- CBQ Core Index Score: This is the measure of the 22 items of the Core Index that are rated “3” or “4”. The Core Index score easily differentiates between children with bipolar disorder and those with ADHD alone (no mood disorder) and indicates the likelihood for inclusion to this phenotype.
- CBQ Total Score: This is the number of all 65 items rated “3” or “4”. In general terms, the higher the total score, the more severe the mood disorder.
- CBQ Dimensions of Impairment: Quantitative analysis has grouped together 10 clusters of symptoms that represent behavioral dimensions of this disorder. The scoring will provide a measure of the subject’s degree of impairment in each of the dimensional areas. (link to a discussion of behavioral dimensions )
See a scoring sample of the Child Bipolar Questionnaire
If you would like to request a CBQ, you can find that link on the menu to the right at the top of this section or click here. While the CBQ is available for personal use, and we hope you will take advantage of it, we encourage you to simultaneously submit the information to our data bank. The ongoing submission of data will allow our Consortium to continue their important research.
As A Research Tool
Since 2003, the CBQ has collected profile data on over 19,000 children with a community diagnosis of bipolar disorder or at risk for the disorder. The large numbers of subject profiles have allowed investigators to:
- identify a highly heritable trait of the disorder
- identify a new view of the disorder based on behavioral dimensions
- determine the heritability of the resulting dimensions through concordance analysis
- further refine and investigate the most salient heritable features
- arrive at a highly refined, clinically homogeneous and heritable phenotype, called the FOH phenotype, which can easily be identified by 4 factors of the CBQ with 96% accuracy.
- propose a hypothesis of the underlying biology of the FOH phenotype as well as identify a potential biomarker for the illness.
(To learn more about this research, links are provided at the end of this section.)
The effectiveness of the CBQ to rapidly, inexpensively and accurately identify phenotypes of PBD eliminates obstacles posed by previous screening and diagnostic instruments. This not only facilitates the collection of large amounts of data, but also provides a source for recruiting subjects. At this time, profiles that meet the FOH criteria are arriving at a rate of 8-10 per week. We are hopeful that this channel will provide the robust pools of homogeneous DNA that are needed for meaningful genetic evaluation. The current Chronobiology Study, which examines the relationship between thermal dysregulation and circadian rhythm as a biomarker for the illness, has recruited subjects from this channel. (link to Chronobiology Study)
Additionally, the inherent flexibility of the CBQ ensures that it will continue to be a means to identify other behavioral subtypes in the future. The broad scope of symptoms it captures can be examined and re-examined under the focus of different lenses. As the field of psychiatric research moves more into a dimensional, rather than categorical framework, the data will stand ready to continue yielding specific subtypes that can lead to more insight and better, more targeted treatment.
link to description of Core phenotype
link to description of FOH phenotype
Discussions of JBRF sponsored research can be found at the following locations on this site:
About JBD: According to JBRF Sponsored Research: Definition and Approach
Research Studies: Context and Summary of JBRF Sponsored Research
and in the following articles as published in the Journal of Affective Disorders:
Obsessive fears about harm to self or others and overt aggressive behaviors in youth diagnosed with juvenile-onset bipolar disorder
The child bipolar questionnaire: A dimensional approach to screening for pediatric bipolar disorder
A strategy for identifying phenotypic subtypes: Concordance of symptom dimensions between sibling pairs who met screening criteria for a genetic linkage study of childhood-onset bipolar disorder using the Child Bipolar Questionnaire
Fear of harm, a possible phenotype of pediatric bipolar disorder: A dimensional approach to diagnosis for genotyping psychiatric syndromes
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New: Are you interested in finding
out if your children qualify to participate in the JBRF's research studies?
Learn more here.
About the Child Bipolar Questionnaire (CBQ) and The Jeannie & Jeffrey Illustrated Interview for Children (J/J)
Request for the CBQ or J/J
Research Studies
Context and Summary of JBRF Sponsored Research
Biological Consistency
Genome-wide Association Scan
Chronobiology Study
Stem Cell Study
Clinical Phenomenological
Study of Childhood-onset Bipolar Disorder
Neuropsychological Testing
in Juvenile-onset Bipolar Disorder
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