Diagnostic implications of informant disagreement for manic symptoms

This study examines diagnoses that occur in an outpatient sample when both parent and teacher endorse significant manic symptoms and when only a parent observes them. We hypothesized that the diagnosis of mania/bipolar (BP) disorder would occur when there is parent/teacher concordance on high mania symptom scores.

Subjects were 911 5-18-year-old psychiatrically diagnosed youths with caregiver and teacher completed Child Mania Rating Scales (CMRSs) and Achenbach parent and teacher forms. Parent-teacher concordance on the CMRS was defined as both informants ≥75 percentile on the CMRS; discordance on the CMRS was defined as parent ≥75 percentile and teacher ≤25 percentile. Logistic regression examined factors associated with a child's parent and teacher ratings concordant for high CMRS total scores.

Correlation between parent CMRS (CMRS-P) and teacher CMRS (CMRS-T) scores was r=0.27 (p<0.000). Correlation between the CMRS-P and the Child Behavior Checklist "bipolar/dysregulation" phenotype was r=0.757 and between the CMRS-T and Teacher Report Form "bipolar/dysregulation" phenotype was r=0.786. A total of 66 (7.3%) of the 911 children were diagnosed with BP I (n=20) or II (n=3) or BP disorder not otherwise specified (BPNOS, n=43). If the CMRS-P score was ≥15, 14.7% (vs. 4.4%) had any BP (odds ratio: 3.6; 95% confidence interval: 2.1, 6.2). Teacher agreement or disagreement did not add to diagnostic accuracy for students with BP I or II. BPNOS was more common in children with concordant high CMRS-P and CMRS-T ratings (10.5% vs. 4.8%) but the difference was not statistically significant. However, logistic regression indicated 10-fold greater odds of both parents and teachers, providing high CMRS ratings among children who were diagnosed with externalizing disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, or any combination of these). Children with internalizing disorders (anxiety and depressive disorders) were 3.7 times more likely to have discordant CMRS-P/CMRS-T ratings.

Parent and teacher concordance on high mania rating scale scores was most associated with externalizing disorders, and discordance was most associated with internalizing disorders.