Discerning ADHD from Bipolar Disorder in Children and Adolescents

Under-Charted Waters: Discerning ADHD from Bipolar Disorder in Children and Adolescents

By Kenneth Duckworth, M.D., NAMI Medical Consultant

Source: NAMI Beginnings/Issue 5/Summer 2004

Many people ask me about the relationship between attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder, and how to differentiate the two. Let me explain how I understand the travels through these under-charted waters.

We Are All New Here

First, remember that bipolar disorder in children is a relatively new conceptual framework. When I was trained in child psychiatry at Harvard in the early 1990s, I was taught that bipolar disorder occurred in one’s twenties or thirties. But recall that in the 1960s, clinicians did not conceptualize depression in kids-it didn’t fit the model. The conceptual framework taught us that depression was a byproduct of our critical conscience-called the superego-and kids were not developed in that area yet, so they were thought to be unable to experience depression. Then researchers decided to actually interview kids, and found that some were persistently sad, had no sense of future, had thoughts of self-harm, and were having sleep and energy problems. Although bipolar disorder, unlike depression, had no clear-cut psychological model, clinicians also just assumed that it didn’t occur early. As we look back, that seems unusual, as schizophrenia and depression can present early.

In 1995, Harvard researchers led by Janet Wozniak, M.D., described the phenomenon by assessing kids and noting that some kids with ADHD were having multiple symptoms that were not easy to explain by ADHD alone. The consensus is now that this was a major step forward, but the margins or outside elements of the condition are controversial. ADHD is thought to be much more common, but that condition also does not have diagnostic precision. Impulsiveness and hyperactivity go with both diagnoses, so you can’t stop there.

Watch the Movie, not the Trailer

Diagnosis is longitudinal, not a one time thing. The course and impact of a person’s symptoms are of paramount importance in making a diagnosis. This means seeing the child over time, reviewing records, and talking with parents about the temperament of the child as an infant. In my practice, I do not make a diagnosis quickly; I identify a lead diagnosis and stay open to the fact that new information will allow revision.

Seeing symptoms in a context over time is crucial for adult diagnosis as well.

A single interview should not a diagnosis make. For instance, bipolar disorder in kids is more episodic, and ADHD is more consistent. A child presenting with severe depression has to be seen over time to see if a manic episode follows.

Show More than Tell

Children may present distress with physical symptoms rather than with words. “Frequent Flyers” in school nurses’ offices are sometimes expressing emotional distress. Kids are also not thought to be good at self-reporting things like sleep patterns, the disturbance of which is consistent with bipolar disorder. Some kids, however can easily discuss their emotional state.

In older kids, I watch for how they are doing with their peers; as the job of adolescents is to develop a separate identity and transition out of the home, they may not turn to their parents. But if they do not turn to their friends, I know there is some distress there. Distress is not a diagnosis, however.

Respect the Elders

Family history is a key clue, and one that is underutilized in sorting out clinical puzzles. ADHD and bipolar disorder both have a strong family inheritance, and ADHD has one of the strongest familial linkages in the field of psychiatry. Bipolar disorder in family members should be a clue, but is not a lynchpin. Alcoholism and completed suicide in grandparents do not necessarily indicate a family history of bipolar disorder, but they suggest that mood symptoms may have been self-medicated with alcohol. Ninety percent of suicides are associated with a psychiatric diagnosis, often mood disorder.

Both adults and children who take antidepressants should have a handle on their family risk, as manic symptoms can be precipitated by antidepressants if not planned for. I just saw an adolescent today who had manic symptoms that were uncovered by antidepressants. In talking with the family, I learned that manic symptoms were many. It is clear that this was an unnecessary risk for the young man, and a better history would have shown that.

Both Conditions Have Concerns with Common Theme: Quest for Self-Regulation

Strategies that teach self-regulation are useful for many conditions. Occupational therapists talk of a “sensory diet,” which is a useful framework for our efforts. Teaching people to modulate their inputs and their responses is a key life skill, but one I was not taught. Parents often intuit this with an ADHD child-you can’t do three things in one day and expect that they can filter out all the stimuli. Family psychoeducation approaches can help to give people this language and framework. Classrooms that have a lone desk aside the teachers can be a tool for awareness. If it is a desk any child can use, the child is learning to notice his or her own state and develop a strategy (going to a quieter spot). This is preferable to one desk being assigned to a single child, as that strategy does not teach the child how to reflect on his or her own sensory state.

I also like martial arts, as it is all about developing control over one’s impulses and body. Exercise is also good-kids notice they feel more relaxed afterward-and it taps into emerging research that shows that the cerebellum, a part of the brain responsible for balance and some movement coordination, may have a useful role in improving executive functions.

We Need Better Research

Snapshot research does not get us where we need to go. We need to better understand how interventions play out in different kids over time. This is true for medicines that are not FDA approved for kids, like valproic acid, and also for other interventions, like family psychoeducation. There is no Framingham Heart study of kids with different presentations and symptoms that follows them into adulthood. This is a profound missed opportunity, as we have so many more tools for intervention. We also need to ensure a supply of capable child psychiatrists-I would not want a pediatrician to try to keep up with the emerging literature in child psychiatry. I have not discussed medications in this article because the focus is more on diagnosis.

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