The Mania Rating Scale: Can It Be Used in Children? A Preliminary Report MARY A. FRISTAD, PHD., ELIZABETH B. WELLER, M.D.,
AND
RONALD A. WELLER, M.D.
Abstract. The Mania Rating Scale (MRS) was evaluated for use in prepubertal children. Eleven manic and II matched controls with attention-deficit hyperactivity disorder were examined. MRS scores were significantly higher in manic versus ADHD children (p < 0.0001), while scores on hyperactivity rating scales (Conners-Parent and Teacher Forms) did not differ between groups. Most individual MRS item scores differed significantly between groups (p < 0.05). MRS scores correlated significantly with severity of mania (Clinical Global Impression-Mania, r = 0.84; p < 0.0001). Age, race, and sex were not correlated with MRS scores. The MRS may be useful in differentiating mania from ADHD and determining the severity of mania in prepubertal children. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 2:252-257. Key Words: bipolar disorder, mania, children, assessment. There have been several reports of mania occurring in children (Tomasson and Kuperman, 1990; Varanka et aI., 1988). In DSM-III-R (American Psychiatric Association, 1987), the criteria for diagnosing mania in children are described as being the same as for adults. Although the exact Occurrence of mania in children is unknown, it may have been underdiagnosed in the past (Weller et aI., 1986). However, making the diagnosis of mania in children can be difficult (ColI and Bland, 1979; Jemerin et aI., 1988; Strober and Carlson, 1982; Strober et aI., 1990). In particular, the differential diagnosis of mania versus attention deficit hyperactivity disorder (ADHD) has been considered problematic (ColI and Bland, 1979). Just as rating scales to assess depressive symptoms in children have proven useful (Costello and Angold, 1988), similar instruments to assess manic symptoms in this age group would also be helpful. For example, standardized instruments to quantify observed phenomenology and rate severity of mania would aid in the systematic investigation of mania in children. In adults, several scales have been used to rate the severity of mania. They include the Mania Rating Scale (MRS) (Young et aI., 1978), the Rating of Manic States (Petterson et aI., 1973), the Manic State Rating Scale (Beigel et aI., 1971), and the Modified Manic-State Rating Scale (Blackburn et aI., 1977). Of these, the latter has been used with adolescents (Strober et aI., 1988), but none have been used with prepubertal children. Before scales developed for adults can be routinely used in children, their reliability and validity must be determined in this younger age group. The purpose of this study was to determine the ability of
/ /
Accepted July 23, 1991. From the Ohio State University Department of Psychiatry and Neurosciences Program, Columbus, Ohio. This paper was presented in part at the 36th Annual Convention of the American Academy of Child and Adolescent Psychiatry. The authors thank Linda McCormick, who assisted in data collection, Gail Gill, M.A., who performed the statistical analyses, and Stana Paulauskas, Ph.D., who provided clinical evaluations. Funding for this paper came from Ohio State University Bremer and Seed Grants. Reprint Requests to Dr. Fristad, Department of Psychiatry, The Ohio State University, Columbus, OH 43210-1228 0890-8567/92/3102-D252$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry.
252
the MRS (Appendix) to differentiate prepubertal children with mania from those with ADHD. It was decided to test the MRS in prepubertal children as it was not as lengthy as the Modified Manic State Rating Scale (11 versus 28 items), and the MRS has been reported to assess severity of mania in adults better than either the Rating of Manic States (Petterson et aI., 1973) or the Manic State Rating Scales (Beigel et aI., 1971). To provide a basis for clinical comparison with the MRS, the Clinical Global Impression-Mania (CGI-M) scale was developed (Fristad et aI., unpublished, 1988) to categorize the severity of children's manic episodes according to DSMIII-R criteria. Scores on the CGI-M could range from 1 (absent) to 5 (severe). To determine if the MRS could differentiate mania from ADHD, manic children were compared with matched ADHD control children. Both groups received the MRS, the CGI-M, and two commonly used hyperactivity rating scales (Conners-Parent and Teacher Forms) (Conners, 1973). Thus, it would be possible to determine if 1) the MRS differentiated manic from hyperactive children better than standard hyperactivity rating scales did, and 2) the MRS scores were significantly and positively correlated with CGI-M scores.
Method Subjects
Subjects were 11 children with a primary DSM-III-R diagnosis of bipolar disorder, mixed or manic type, and 11 children with a primary DSM-III-R diagnosis of ADHD. Previous diagnoses of ADHD had been made in most of the bipolar group. Four of the ADHD children had an additional diagnosis of oppositional-defiant disorder and two others had conduct disorder. None had a secondary mood disorder. Initial clinical diagnoses were made using a semistructured interview, then independently confirmed by structured diagnostic interviews as described below. Subjects gave assent, and their parents gave consent for participation in the study. Both subject groups were obtained from prepubertal patients aged 6 to 12 consecutively evaluated at a university medical center with inpatient and outpatient facilities. The bipolar group was recruited over a 17month period from a mood disorders program. All had a past history of behavior problems, extreme irritability, and J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992
USING THE MANIA RATING SCALE WITH CHILDREN
mood swings. Most (N = 8) had been identified as having ADHD as preschoolers, and attempts to treat the ADHD had been unsuccessful. All subjects had a history suggestive of previous manic or hypomanic episodes. A history of periodic mood swings also was frequently reported. Current episodes of mania involved classic symptoms, including "flying around like a kite," pressured speech, flight of ideas, nonsensical rhyming, extreme hyperactivity, sexual preoccupation, and grandiosity. Past episodes of depression were definite (e.g., had been treated for major depression episode) or probable (e.g., the child was reported to be sad, have low self-esteem, suicidal ideation, and self-injurious behavior) in all but one patient. Previous depressive symptoms including dysphoric mood, excessive crying, morbid and suicidal ideation, social withdrawal, sleep and appetite changes, and impaired concentration and self-esteem. The two groups did not differ significantly in age (X ::!: SD: bipolar group, 8.7 years::!: 1.7; ADHD group, 8.8 years ::!: 2.4; t = -0.10, df = 20, NS), sex (bipolar group, 10 boys; ADHD group, 9 boys; Yates corrected X2 = 0; df = 1; NS), or race (bipolar group, 11 Caucasian; ADHD group, 9 Caucasian, 2 black; Yates' corrected X2 = 0.005; df = 1; NS) distribution between groups.
Instruments The Diagnostic Interview for Children and Adolescents Revised (DICA-R) - Child and Parent Forms (Reich and WeIner, 1988) are structured psychiatric interviews designed to assess psychopathology according to DSM-III-R criteria in children and adolescents ages 6 to 17 years. High testretest reliability and moderate correlations with chart diagnoses have been demonstrated previously (Reich et aI., 1982). These interviews were used to confirm diagnoses of mania and ADHD. The MRS is an ll-item clinical rating scale for manic symptoms (Young et aI., 1978). Items are rated either from o to 4 (N = 7) or 0 to 8 (N = 4), depending on item weighing, in the direction of increasing severity. The total score can range from 0 to 60. Reliability and validity are acceptable in adults (Young et aI., 1978). Scores were made by the clinician after combining impressions from the child's and parents' clinical interviews, as is standard practice in child and adolescent psychiatry. This is in contrast to adults, where administration of the MRS is done by interviewing the patient alone. No other changes in administering or scoring the MRS were made. The CGI-M is a global rating of the child's degree of manic symptoms (Fristad et aI., unpublished, 1988) according to DSM-III-R guidelines. It was developed to provide a clinical severity rating to compare with the MRS. It was scored as follows: 1, absent; 2, doubtful diagnosis; 3, mild severity; 4, moderate severity; and 5, extreme severity. The Conners' Parent Rating Scale (Conners-P) is a widely-used instrument developed to assess hyperactivity in children (Conners, 1973). Norms and reliability for the instrument are excellent (Glow et aI., 1982; Goyette et aI., J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992
1978). The lO-item Hyperactivity Index derived from the scale (Conners, 1973) was used in this study. The Conners Revised Teacher Rating Scale (Conners-T) is a widely used scale that assesses hyperactivity in children (Conners, 1973). As with the parent version, normative data and reliability for the instrument are excellent (Glow et aI., 1982; Goyette et al., 1978). The lO-item Hyperactivity Index derived from the scale (Conners, 1973) was used in this study.
Procedure The mCA was administered by a psychometrist experienced in the administration of structured interviews in this population. The MRS and the CGI-M were completed after a thorough standardized evaluation of the child. Parents completed the Conners-P and teachers completed the Conners-T before the child's evaluation. Conners-T were missing for two manic and four ADHD children. All other data were complete. All ratings (except the MRS and CGI-M) were made blind to one another and to diagnostic status. Nine of the 11 bipolar children were inpatients rated by one of the authors (EW). Two were outpatients, each rated by one of the authors (EW or MF). Of the 11 ADHD control children, eight were evaluated by one of the authors (MF) and three were evaluated by another doctoral level clinical child psychologist well trained in the use of these rating scales.
Data Analysis Analyses were performed using the SAS statistical program (SAS Institute, 1985). All t-tests were two-tailed. When variances were unequal between groups on t-tests, corrections were made using Satterthwaite's approximation for degrees of freedom (Satterthwaite, 1946). Results
Discriminant Validity T-tests were conducted to test for differences on the MRS, CGI-M, Conners-T, and Conners-Pbetween the two groups. Scores on the MRS and the CGI-M were significantly higher for the manic children compared with the ADHD children. They were also nonoverlapping, i.e., manic children received scores of 14 to 39 on the MRS and scores of 3 to 5 on the CGI-M, whereas children with ADHD received scores of o to 12 on the MRS and 1 to 2 on the CGI-M. Scores on the two hyperactivitY rating scales, Conners-P and ConnersT, did not differ significantly between groups (Table 1). Next, item comparisons were made for the MRS to determine which specific items received significantly higher endorsement in the manic versus ADHD group (Table 2). Mean individual item scores for manic children were always higher, indicating greater severity. Differences were statistically significant for seven items and showed a trend toward significance for two items (i.e., p value between 0.05 and 0.10). Scores on two items, sexual interest and appearance, did not differ between groups. Concurrent Validity Pearson correlation coefficients were calculated to deter-
253
FRlSTAD ET AL.
TABLE 1. Comparison of Mania Rating Scale (MRS), Clinical Global Impression-Mania (CGI-M), Conners-Parent (Conners-P) and Teacher (Conners- T) Hyperactivity Scale Scores in 11 Children with Mania and 11 Children with ADHD Group Test MRS X:±: SD Range CGI-M X :±: SD Range Conners-P X :±: SD Range Conners-T X :±: SD Range
Mania (N = 11)
ADHD (N = 11)
24.1 :±: 8.1 (14-39)
7.8 :±: 4.8 (0-13)
3.6 :±: 0.5 (3-5)
df
P
5.72
20
0.0001
1.3 :±: 0.5 (1-2)
11.40
20
0.0001
19.7 :±: 5.9 (7-27)
17.3 :±: 3.0 (13-23)
1.24
14.8"
NS
18.0 :±: 10.5 (2-30) (N = 9)
18.4 :±: 8.8 (6-29) (N = 7)
14
NS
-0.09
"Satterwaite's (1946) approximation for degrees of freedom was used to correct for unequal variance.
TABLE 2. Mania Rating Scale Item Endorsement in 11 Children with Mania and 11 Children with ADHD Item X :±: SD (Range) Elevated mood
Group Mania (N =11)
2.2 :±: 1.3 (0-4)
2 Increased motor activity/energy 3 Sexual interest
3.1 :±: 0.7 (2-4) 0.6 :±: 1.2 (0-4)
4 Sleep 5 Irritability 6 Speech (Rate and amount) 7 Flight of ideas 8 Thought content
1.2 :±: 1.3 (0-3) 4.7 :±: 1.4 (0-8) 3.5 :±: 2.3 (0-8) 1.1 :±: 1.2 (0-3) 1.8 :±: 2.8 (0-6)
9 Disruptive/aggressive behavior 10 Appearance
11 Insight
3.8 :±: 1.9 (5-6) 0.5 :±: 0.5 (0-1) 1.6 :±: 1.5 (0-4)
a
ADHD (N = 11)
0.3 :±: 0.5 (0-1) 2.3 :±: 1.2 (0-3) 0.5 :±: 1.3 (0-4) 0.0 :±: 0.0
df
P
4.50
12.4"
0.0007
1.96
20
0.06
0.17
20
NS
2.95
10
0.01
3.73
20
0.001
3.41
20
0.003
3.18
10
om
1.93
11
0.08
4.17
14.6"
0.004
1.37
20
NS
2.11
20
0.05
(0-0)
2.1 :±: 1.9 (0-4)
0.6 :±: 1.4 (0-4) 0.0 :±: 0.0 (0-0)
0.2 :±: 0.6 (0-2) 1.1 :±: 0.9 (0-2) 0.2 :±: 0.4 (0-1) 0.5 :±: 0.8 (0-2)
Satterwaite's (1946) approximation for degrees of freedom was used to correct for unequal variance.
mine the relationship between MRS and CGI-M scores. These were highly significant (r = 0.84; p < 0.0001). In each case, as CGI-M global severity scores increased, mean MRS scores increased. Internal Consistency Item-total correlations for the MRS were calculated (Table 3). Item-total correlations were calculated to assess the degree of relationship between individual items and the total score. Such correlations can be used as an index of internal consistency to determine if the scale measures one construct
254
(Ferguson, 1981). The magnitude of correlations indicated a moderate to high degree of intercorrelation (r = 0.70 0.86) for eight of the items, low intercorrelation (r = 0.45) for one item (appearance), and no significant intercorrelations (rs = 0.13 and 0.34) for two items (sexual interest and insight). Impact of Demographic Variables on Test Scores Correlational analyses did not show a significant relationship between age, race, and sex and the MRS and CGI-M. J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992
USING THE MANIA RATING SCALE WITH CHILDREN
3. Item-Total Correction of the Mania Rating Scale (MRS) in I I Children with Mania and I I Children with ADHD
TABLE
Item
Item Content
r
p
AND
RONALD A. WELLER, M.D.
Abstract. The Mania Rating Scale (MRS) was evaluated for use in prepubertal children. Eleven manic and II matched controls with attention-deficit hyperactivity disorder were examined. MRS scores were significantly higher in manic versus ADHD children (p < 0.0001), while scores on hyperactivity rating scales (Conners-Parent and Teacher Forms) did not differ between groups. Most individual MRS item scores differed significantly between groups (p < 0.05). MRS scores correlated significantly with severity of mania (Clinical Global Impression-Mania, r = 0.84; p < 0.0001). Age, race, and sex were not correlated with MRS scores. The MRS may be useful in differentiating mania from ADHD and determining the severity of mania in prepubertal children. J. Am. Acad. Child Adolesc. Psychiatry, 1992, 31, 2:252-257. Key Words: bipolar disorder, mania, children, assessment. There have been several reports of mania occurring in children (Tomasson and Kuperman, 1990; Varanka et aI., 1988). In DSM-III-R (American Psychiatric Association, 1987), the criteria for diagnosing mania in children are described as being the same as for adults. Although the exact Occurrence of mania in children is unknown, it may have been underdiagnosed in the past (Weller et aI., 1986). However, making the diagnosis of mania in children can be difficult (ColI and Bland, 1979; Jemerin et aI., 1988; Strober and Carlson, 1982; Strober et aI., 1990). In particular, the differential diagnosis of mania versus attention deficit hyperactivity disorder (ADHD) has been considered problematic (ColI and Bland, 1979). Just as rating scales to assess depressive symptoms in children have proven useful (Costello and Angold, 1988), similar instruments to assess manic symptoms in this age group would also be helpful. For example, standardized instruments to quantify observed phenomenology and rate severity of mania would aid in the systematic investigation of mania in children. In adults, several scales have been used to rate the severity of mania. They include the Mania Rating Scale (MRS) (Young et aI., 1978), the Rating of Manic States (Petterson et aI., 1973), the Manic State Rating Scale (Beigel et aI., 1971), and the Modified Manic-State Rating Scale (Blackburn et aI., 1977). Of these, the latter has been used with adolescents (Strober et aI., 1988), but none have been used with prepubertal children. Before scales developed for adults can be routinely used in children, their reliability and validity must be determined in this younger age group. The purpose of this study was to determine the ability of
/ /
Accepted July 23, 1991. From the Ohio State University Department of Psychiatry and Neurosciences Program, Columbus, Ohio. This paper was presented in part at the 36th Annual Convention of the American Academy of Child and Adolescent Psychiatry. The authors thank Linda McCormick, who assisted in data collection, Gail Gill, M.A., who performed the statistical analyses, and Stana Paulauskas, Ph.D., who provided clinical evaluations. Funding for this paper came from Ohio State University Bremer and Seed Grants. Reprint Requests to Dr. Fristad, Department of Psychiatry, The Ohio State University, Columbus, OH 43210-1228 0890-8567/92/3102-D252$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry.
252
the MRS (Appendix) to differentiate prepubertal children with mania from those with ADHD. It was decided to test the MRS in prepubertal children as it was not as lengthy as the Modified Manic State Rating Scale (11 versus 28 items), and the MRS has been reported to assess severity of mania in adults better than either the Rating of Manic States (Petterson et aI., 1973) or the Manic State Rating Scales (Beigel et aI., 1971). To provide a basis for clinical comparison with the MRS, the Clinical Global Impression-Mania (CGI-M) scale was developed (Fristad et aI., unpublished, 1988) to categorize the severity of children's manic episodes according to DSMIII-R criteria. Scores on the CGI-M could range from 1 (absent) to 5 (severe). To determine if the MRS could differentiate mania from ADHD, manic children were compared with matched ADHD control children. Both groups received the MRS, the CGI-M, and two commonly used hyperactivity rating scales (Conners-Parent and Teacher Forms) (Conners, 1973). Thus, it would be possible to determine if 1) the MRS differentiated manic from hyperactive children better than standard hyperactivity rating scales did, and 2) the MRS scores were significantly and positively correlated with CGI-M scores.
Method Subjects
Subjects were 11 children with a primary DSM-III-R diagnosis of bipolar disorder, mixed or manic type, and 11 children with a primary DSM-III-R diagnosis of ADHD. Previous diagnoses of ADHD had been made in most of the bipolar group. Four of the ADHD children had an additional diagnosis of oppositional-defiant disorder and two others had conduct disorder. None had a secondary mood disorder. Initial clinical diagnoses were made using a semistructured interview, then independently confirmed by structured diagnostic interviews as described below. Subjects gave assent, and their parents gave consent for participation in the study. Both subject groups were obtained from prepubertal patients aged 6 to 12 consecutively evaluated at a university medical center with inpatient and outpatient facilities. The bipolar group was recruited over a 17month period from a mood disorders program. All had a past history of behavior problems, extreme irritability, and J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992
USING THE MANIA RATING SCALE WITH CHILDREN
mood swings. Most (N = 8) had been identified as having ADHD as preschoolers, and attempts to treat the ADHD had been unsuccessful. All subjects had a history suggestive of previous manic or hypomanic episodes. A history of periodic mood swings also was frequently reported. Current episodes of mania involved classic symptoms, including "flying around like a kite," pressured speech, flight of ideas, nonsensical rhyming, extreme hyperactivity, sexual preoccupation, and grandiosity. Past episodes of depression were definite (e.g., had been treated for major depression episode) or probable (e.g., the child was reported to be sad, have low self-esteem, suicidal ideation, and self-injurious behavior) in all but one patient. Previous depressive symptoms including dysphoric mood, excessive crying, morbid and suicidal ideation, social withdrawal, sleep and appetite changes, and impaired concentration and self-esteem. The two groups did not differ significantly in age (X ::!: SD: bipolar group, 8.7 years::!: 1.7; ADHD group, 8.8 years ::!: 2.4; t = -0.10, df = 20, NS), sex (bipolar group, 10 boys; ADHD group, 9 boys; Yates corrected X2 = 0; df = 1; NS), or race (bipolar group, 11 Caucasian; ADHD group, 9 Caucasian, 2 black; Yates' corrected X2 = 0.005; df = 1; NS) distribution between groups.
Instruments The Diagnostic Interview for Children and Adolescents Revised (DICA-R) - Child and Parent Forms (Reich and WeIner, 1988) are structured psychiatric interviews designed to assess psychopathology according to DSM-III-R criteria in children and adolescents ages 6 to 17 years. High testretest reliability and moderate correlations with chart diagnoses have been demonstrated previously (Reich et aI., 1982). These interviews were used to confirm diagnoses of mania and ADHD. The MRS is an ll-item clinical rating scale for manic symptoms (Young et aI., 1978). Items are rated either from o to 4 (N = 7) or 0 to 8 (N = 4), depending on item weighing, in the direction of increasing severity. The total score can range from 0 to 60. Reliability and validity are acceptable in adults (Young et aI., 1978). Scores were made by the clinician after combining impressions from the child's and parents' clinical interviews, as is standard practice in child and adolescent psychiatry. This is in contrast to adults, where administration of the MRS is done by interviewing the patient alone. No other changes in administering or scoring the MRS were made. The CGI-M is a global rating of the child's degree of manic symptoms (Fristad et aI., unpublished, 1988) according to DSM-III-R guidelines. It was developed to provide a clinical severity rating to compare with the MRS. It was scored as follows: 1, absent; 2, doubtful diagnosis; 3, mild severity; 4, moderate severity; and 5, extreme severity. The Conners' Parent Rating Scale (Conners-P) is a widely-used instrument developed to assess hyperactivity in children (Conners, 1973). Norms and reliability for the instrument are excellent (Glow et aI., 1982; Goyette et aI., J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992
1978). The lO-item Hyperactivity Index derived from the scale (Conners, 1973) was used in this study. The Conners Revised Teacher Rating Scale (Conners-T) is a widely used scale that assesses hyperactivity in children (Conners, 1973). As with the parent version, normative data and reliability for the instrument are excellent (Glow et aI., 1982; Goyette et al., 1978). The lO-item Hyperactivity Index derived from the scale (Conners, 1973) was used in this study.
Procedure The mCA was administered by a psychometrist experienced in the administration of structured interviews in this population. The MRS and the CGI-M were completed after a thorough standardized evaluation of the child. Parents completed the Conners-P and teachers completed the Conners-T before the child's evaluation. Conners-T were missing for two manic and four ADHD children. All other data were complete. All ratings (except the MRS and CGI-M) were made blind to one another and to diagnostic status. Nine of the 11 bipolar children were inpatients rated by one of the authors (EW). Two were outpatients, each rated by one of the authors (EW or MF). Of the 11 ADHD control children, eight were evaluated by one of the authors (MF) and three were evaluated by another doctoral level clinical child psychologist well trained in the use of these rating scales.
Data Analysis Analyses were performed using the SAS statistical program (SAS Institute, 1985). All t-tests were two-tailed. When variances were unequal between groups on t-tests, corrections were made using Satterthwaite's approximation for degrees of freedom (Satterthwaite, 1946). Results
Discriminant Validity T-tests were conducted to test for differences on the MRS, CGI-M, Conners-T, and Conners-Pbetween the two groups. Scores on the MRS and the CGI-M were significantly higher for the manic children compared with the ADHD children. They were also nonoverlapping, i.e., manic children received scores of 14 to 39 on the MRS and scores of 3 to 5 on the CGI-M, whereas children with ADHD received scores of o to 12 on the MRS and 1 to 2 on the CGI-M. Scores on the two hyperactivitY rating scales, Conners-P and ConnersT, did not differ significantly between groups (Table 1). Next, item comparisons were made for the MRS to determine which specific items received significantly higher endorsement in the manic versus ADHD group (Table 2). Mean individual item scores for manic children were always higher, indicating greater severity. Differences were statistically significant for seven items and showed a trend toward significance for two items (i.e., p value between 0.05 and 0.10). Scores on two items, sexual interest and appearance, did not differ between groups. Concurrent Validity Pearson correlation coefficients were calculated to deter-
253
FRlSTAD ET AL.
TABLE 1. Comparison of Mania Rating Scale (MRS), Clinical Global Impression-Mania (CGI-M), Conners-Parent (Conners-P) and Teacher (Conners- T) Hyperactivity Scale Scores in 11 Children with Mania and 11 Children with ADHD Group Test MRS X:±: SD Range CGI-M X :±: SD Range Conners-P X :±: SD Range Conners-T X :±: SD Range
Mania (N = 11)
ADHD (N = 11)
24.1 :±: 8.1 (14-39)
7.8 :±: 4.8 (0-13)
3.6 :±: 0.5 (3-5)
df
P
5.72
20
0.0001
1.3 :±: 0.5 (1-2)
11.40
20
0.0001
19.7 :±: 5.9 (7-27)
17.3 :±: 3.0 (13-23)
1.24
14.8"
NS
18.0 :±: 10.5 (2-30) (N = 9)
18.4 :±: 8.8 (6-29) (N = 7)
14
NS
-0.09
"Satterwaite's (1946) approximation for degrees of freedom was used to correct for unequal variance.
TABLE 2. Mania Rating Scale Item Endorsement in 11 Children with Mania and 11 Children with ADHD Item X :±: SD (Range) Elevated mood
Group Mania (N =11)
2.2 :±: 1.3 (0-4)
2 Increased motor activity/energy 3 Sexual interest
3.1 :±: 0.7 (2-4) 0.6 :±: 1.2 (0-4)
4 Sleep 5 Irritability 6 Speech (Rate and amount) 7 Flight of ideas 8 Thought content
1.2 :±: 1.3 (0-3) 4.7 :±: 1.4 (0-8) 3.5 :±: 2.3 (0-8) 1.1 :±: 1.2 (0-3) 1.8 :±: 2.8 (0-6)
9 Disruptive/aggressive behavior 10 Appearance
11 Insight
3.8 :±: 1.9 (5-6) 0.5 :±: 0.5 (0-1) 1.6 :±: 1.5 (0-4)
a
ADHD (N = 11)
0.3 :±: 0.5 (0-1) 2.3 :±: 1.2 (0-3) 0.5 :±: 1.3 (0-4) 0.0 :±: 0.0
df
P
4.50
12.4"
0.0007
1.96
20
0.06
0.17
20
NS
2.95
10
0.01
3.73
20
0.001
3.41
20
0.003
3.18
10
om
1.93
11
0.08
4.17
14.6"
0.004
1.37
20
NS
2.11
20
0.05
(0-0)
2.1 :±: 1.9 (0-4)
0.6 :±: 1.4 (0-4) 0.0 :±: 0.0 (0-0)
0.2 :±: 0.6 (0-2) 1.1 :±: 0.9 (0-2) 0.2 :±: 0.4 (0-1) 0.5 :±: 0.8 (0-2)
Satterwaite's (1946) approximation for degrees of freedom was used to correct for unequal variance.
mine the relationship between MRS and CGI-M scores. These were highly significant (r = 0.84; p < 0.0001). In each case, as CGI-M global severity scores increased, mean MRS scores increased. Internal Consistency Item-total correlations for the MRS were calculated (Table 3). Item-total correlations were calculated to assess the degree of relationship between individual items and the total score. Such correlations can be used as an index of internal consistency to determine if the scale measures one construct
254
(Ferguson, 1981). The magnitude of correlations indicated a moderate to high degree of intercorrelation (r = 0.70 0.86) for eight of the items, low intercorrelation (r = 0.45) for one item (appearance), and no significant intercorrelations (rs = 0.13 and 0.34) for two items (sexual interest and insight). Impact of Demographic Variables on Test Scores Correlational analyses did not show a significant relationship between age, race, and sex and the MRS and CGI-M. J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992
USING THE MANIA RATING SCALE WITH CHILDREN
3. Item-Total Correction of the Mania Rating Scale (MRS) in I I Children with Mania and I I Children with ADHD
TABLE
Item
Item Content
r
p
