ADHD, Bi-Polar, or what?
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Is it Bipolar Disorder, ADHD, or What?
The differential diagnosis and comorbidity of bipolar disorder, mania and adhd.
The prevalence of child and adolescent manic depression (bipolar disorder) is said to affect 1% of youth, with equal rates of boys and girls and may be increasing. The diagnosis of bipolar disorder in youth is often very difficult, as the symptoms typically do not follow the symptoms and course of adults with this disorder. Also, there is an overlap of symptoms with several other more common childhood disorders.
Bipolar disorder is a severe mental illness manifested by recurrent episodes of depression, mania and/or mixed symptom states. Children and some adolescents show a much greater percentage of mixed symptoms, expressing both depressive and manic behaviors at the same time (agitated dysphoria) or rapidly fluctuating moods. Children most commonly present with a mixed and dysphoric picture, characterized by frequent short periods of intense emotional ability and irritability rather than classic euphoria. Bipolar disorder beginning in childhood or early adolescence may be a more severe illness than in older adolescent or adult onset disease.
THE DIFFERENTIAL DIAGNOSIS:
In late adolescents with bipolar disorder, the most common mistaken diagnoses are schizophrenia and conduct disorder. Attention deficit hyperactivity disorder has been the main differential problem in prepubertal and early adolescent patients. The difficulty in distinguishing these two disorders is due to the high prevalence of coexisting ADHD among childhood onset bipolar patients and from the overlap of certain DSM-IV criteria for mania and ADHD (hyperactivity, distractibility and impulsivity). Although irritability is one of the most frequent symptoms of mania/hypomania in all ages, it is of little help in the differential diagnosis in children because of its ubiquity across a number of childhood diagnoses, including mania, major depressive disorder, ADHD, autism, and oppositional defiant/conduct disorders. Only a small percentage of children with irritability have mania.
MANIA VS. ADHD:
The differentiation of mania from ADHD is difficult. The response or lack of response to stimulant medications is not diagnostically helpful. Elevated mood and grandiosity are the symptoms best able to distinguish between pediatric bipolar disorder and ADHD. With bipolar disorder, hyperactivity may be more episodic. However, ADHD may be the first manifestation of mania and is often comorbid with mania in children. An overwhelming majority of manic youth also have ADHD. Almost one quarter of youth with ADHD meet the criteria for mania. Prepubertal onset bipolar disorder is a nonspecific chronic rapid cycling mixed manic state that may co-occur with ADHD and conduct disorder or have features of ADHD and/or conduct disorder as the initial manifestation. The high rate of comorbidity of ADHD with bipolar disorder may be an age dependent child manifestation that will decrease with age. The onset of bipolar disorder in patients with a history of ADHD is often between 11 and 12 years of age. Many children who develop bipolar disorder develop a depressive disorder first. Of youth with major depression, up to 1/3 go on to develop mania/bipolar disorder.
WHAT IS MANIA IN CHILDREN?
Mania in children is seldom characterized by euphoric mood; the most common mood disturbance is severe irritability with “affective storms” (prolonged and aggressive temper outbursts). In between outbursts, these children are described as persistently irritable or angry. Manic children often have a decreased need for sleep-not insomnia, but an ability to function well on less sleep than normal. These children frequently receive a diagnosis of conduct disorder. Aggressive symptoms may be the primary reason for the high rate of psychiatric hospitalizations in manic children.
SYMPTOMS WHICH DISTINGUISH MANIA FROM ADHD:
Children are incapable of presenting many manifestations of bipolar symptoms described in adults. Studies have shown that five behavioral symptoms in children/early adolescents aid in correctly diagnosing childhood bipolar disorder. These manic symptoms which do not overlap with ADHD are elation, grandiosity, flight of ideas/racing thoughts, a decreased need for sleep, and hypersexuality (in the in absence of sexual abuse or overstimulation). These five symptoms provide the best discrimination of childhood/early onset bipolar patients from uncomplicated ADHD patients. Irritability, hyperactivity, accelerated speech and distractibility are frequent in both pediatric bipolar disorder and ADHD and are not useful in differentiating between the two disorders. Mixed mania (simultaneous mania and depression) is highly prevalent in childhood bipolar disorder.
POSSIBLE EARLY SIGNS OF BIPOLAR DISORDER:
Many children with bipolar disorder are described by the parents as having had a difficult temperament in infancy. Great caution should be used in making a diagnose of bipolar disorder in a young child with no family history of psychiatric illness because of the difficulties in the diagnosis in young children with this disorder. Bullying may be a developmental age specific manifestation of grandiosity.
RAPID CYCLING IN CHILDHOOD BIPOLAR DISORDER:
When bipolar disorder begins before or soon after puberty, it is often manifested by continuous rapid cycling irritablily and mixed symptoms, which may co-occur with disruptive behavior disorders. The ultradian (essentially continuous) rapid cycling/ mixed state is one in which children switch in and out of depression, irritable mania with explosions and euphoric mania unpredictably and throughout the day, almost everyday, with very little time spent in a regular age appropriate mood state.
OTHER DISORDERS TO CONSIDER:
The hypersexuality associated with mania can mimic the self stimulatory and sexual acting out behaviors associated with children who have been abused or have witnessed adult sexual behavior. There is a risk of over diagnosis of bipolar disorder in children with conduct disorder and ADHD. The manic rating scale (Fristad, Weller and Weller) has acceptable validity and reliability and can help distinguish between manic and hyperactive children. (Fristad, Weller and Weller(1995) The Manic Rating Scale(MRS): Further reliability and validity studies with children. Ann clin Psychiatry 7: 127-132.
The treatment of ADHD in early bipolar disorder is controversial. Concern has been expressed about the use of psychostimulants to treat ADHD in children with mania and these drugs potential risk for triggering affective episodes in vulnerable children. Clinical experience to date, however, suggests that stimulants, in combination with one or more mood stabilizers, seem to be safe and effective in the treatment of children with mania complicated by ADHD and may result in improvement of the ADHD. When the diagnosis of bipolar disorder has been made, the management of these complex children involves ongoing assessment and, frequently, the use of a combination of medications, requiring expertise and experience in dealing with this type of patient. As the bipolar child goes into adolescence, a turbulent and risk taking time, psychiatric management is indicated.
The course of bipolar disorder in children and adolescents is typically a relapsing recurring illness with substantial morbidity. A US self help organization, the Child and Adolescent Bipolar Foundation, has a web site for parents, which offers helpful information to families raising children or teens with early onset bipolar disorder.
Annette Lansford, M.D., FAAP, a sub-board certified developmental behavioral pediatrician in private practice at Carle Clinic in Urbana,IL. She is the medical director of the Carle Child Disability Clinic, an intradisciplinary diagnostic clinic. She is a clinical associate professor of Pediatrics at the University of Illinois School of Medicine at Urbana-Champaign.