Bipolar or ADHD ?

Attention-Deficit Hyperactivity Disorder and Bipolar Disorder in Children: How do they relate?

Melissa Sharpe

 Penn State College of Medicine

2002

 

1. Diagnostic Characteristics based on DSM-IV

 

1. Attention Deficit Disorder is characterized by a persistent pattern of developmentally inappropriate attention or hyperactivity, which has been present for at least 6 months. Onset is before seven years of age and symptoms are present in 2 or more situations (i.e. home, school, work).
2.         There are three subtypes of ADHD:         predominantly inattentive, hyperactive-impulsive, and combined.
3. The inattentive subtype is characterized by careless mistakes, trouble paying attention, difficulty listening, organizing and finishing tasks. Children can be easily distracted or forgetful.
4. Children with the hyperactivity-impulsivity subtype often squirm in seats, fidget, and are always on the go. They may not be able play quietly, and may talk excessively. Impulsive behavior includes blurting out answers, difficulty waiting one’s turn and interrupting or intruding in on others.
5. Bipolar disorder (BPD) has not been studied as extensively in children as it has in adults. This may be because BPD most frequently presents in late adolescence or early twenties.
6. Bipolar disorder is an affective disorder in which the patient experiences cyclic intervals of mania and depression.
7. Mania is characterized by the presence of an abnormally elevated, expansive or irritable mood, which lasts for at least 1 week or requires hospitalization.
8. Mania is also characterized by symptoms of grandiosity, decreased need for sleep, increased talkativeness, flight of ideas, and distractibility. Patients may also have increased goal directed behavior, psychomotor agitation, and excess involvement in pleasurable activities that have a high potential for painful consequences.

iii. Mania is characteristic of Bipolar I. In contrast, bipolar II presents with hypomania. Hypomania is similar to mania but is less severe and does not cause significant impairment in social or cognitive functions. Symptoms of hypomania are present for at least four days

 

1. The clinical presentation of bipolar disorder in children is not always consistent with that of adults.
   1. It has been reported that children under the age of nine with bipolar disorder are more likely to present with irritability and emotional liability. As compared to euphoria, elevated mood, and grandiose delusions present in adult mania. Clinically children often present with moodiness, impulsivity, hyperactivity, and the inability to concentrate. Children are also more likely to have a chronic course or mixed presentation with symptoms of mania and depression occurring simultaneously rather than the typical episodic pattern (Weller, 1994 (Carlson, 1983)).

 

1. Shared Symptoms between ADHD and bipolar disorder.

 

When comparing the presentations of ADHD and bipolar disorder, three of the criteria for the diagnosis of BPD are shared with ADHD. These include distractibility, physical agitation, and talkativeness. Because of the complex and nonspecific presentation, a child with these symptoms may receive a diagnosis of ADHD, BPD or both (Wozniak, 1995). This, impart, has led to current investigation as to the relationship, if any, between the two disorders.

 

• Current and on going Studies.

 

Multiple studies have been preformed suggesting various relationships between ADHD and bipolar disorder. There have been several relationships proposed, some of these are summarized below.

 

1. The first hypothesis suggests that the initial manifestation of prepubertal onset of bipolar disorder is hyperactive behavior. The hyperactivity first becomes apparent around preschool age and is followed by a full manic syndrome later, during grade school. This idea suggests that ADHD may be an early manifestation of bipolar disorder (Geller, 1997). This hypothesis is based on the observation that there is a higher prevalence of ADHD in prepubertal onset BPD than adolescent onset. (Geller, 1995)

 

1. “Complex and Rapid-cycling in bipolar children and adolescents: a preliminary study.” (Geller, Sun, Zimerman, Luby, Frazier, Williams)

Objective: To describe the characteristics and cycling patterns of bipolar disorder occurring in children and adults.

 

Methods: Two groups of subjects with bipolar disorder were studied. The first group was designated the BP pilot sample and contained males and females 6-16 years of age. The second group was the Adol BP, consisting of males and females 12-18 years old.

 

Assessment: (1) The Kiddie-Schedule for Affective Disorders and Schizophrenia-Present State Version-1986 (K-SADS-P-1986) was administered to mothers and subjects separately of both groups. In addition, the evaluator completed the Children’s Global Assessment Scale (CGAS).

 

(2) Diagnosis of ADHD was established in the Adolescent group using the K-SADS-E. ADHD in the BP pilot group was assessed using the 10-item Conners’ Parent Questionnaire. A cut off of >15 were used as an indication of hyperactivity.

 

Results:

1. 80.8% of the total subjects reported rapid cycling patterns. Within the younger group, rapid cycling was reported in 100% of the subjects. Rapid cycling was reported in 70.6% of the older age group (5/17 subjects, at least 13 years old, and none of the subjects less than 9 had a single episode last lasting at least 2 weeks as their only episode). The majority of the subjects displayed a more continuous pattern of cycling, rather than discrete episodes.

 

2. There were no significant differences between younger and older subjects on any of the diagnostic items. However, general trends did show the prevalence of ADHD (hyperactivity) to be higher in the younger age group diagnosed with bipolar as compared to the older group(88.9% of the subjects in the younger group compared to 29.4% in the older group).

 

Authors Conclusions: The continuous nature of the manic episodes creates a challenge in distinguishing ADHD and bipolar disorder. Based on the observation of increased hyperactivity in the younger subjects, the authors suggest that ADHD may be an “age specific manifestation of bipolar disorder.”

 

2. The second hypothesis stems from suggestions by investigators that BPD occurs comorbidly with ADHD (ie. BPD in children is often a subtype of childhood ADHD)

 

1. A Pilot Family Study of Childhood-Onset Mania (Wozniak, Biederman, Mundy, Mennin, Faraone)

 

Objective: To investigate the familial association of ADHD and BPD among first-degree relatives of children with comorbid ADHD and BPD.

 

Method: Three groups were studied. The first was composed of first-degree relatives of children previously diagnosed with BPD (BPD sample). The second group was composed of first-degree relatives of children diagnosed with ADHD without bipolar disorder (ADHD sample). The third group was made up of first-degree relatives of normal controls (control sample). Each group underwent identical structured clinical interviews using the               K-SADS-E.

 

Results:

Proband

1. Of those children diagnosed with BPD, 94% also met criteria for ADHD at time of study.

 

Familial Analysis

2. 13% of the first-degree relatives of the BPD sample met the criteria for mania with associated impairment. This was significantly greater than the ADHD group or control group (2% and 7 %, respectively). The ADHD group and control group were not significantly different from each other.

 

3. 26% of the first-degree relatives of the BPD group met the criteria for ADHD. 16% of the relative of the ADHD group met the criteria for ADHD (This was not significantly different from the BPD group). Both the BPD and ADHD groups had higher rates of ADHD than the control group (6%).

 

4. Analysis of the first-degree relatives of the children with BPD + ADHD (see # 1) revealed that 42% of the relatives diagnosed with ADHD (see #2) also met the criteria for BPD. In contrast to this, only 3% of the ADHD relatives of children with ADHD without BPD met the criteria for BPD.

 

Authors Conclusions: The data suggest that BPD and ADHD exist comorbidly. The authors conclude that cosegregation between bipolar disorder and ADHD may be a distinct familial syndrome of childhood-onset mania. This is supported by the marked comorbidity of ADHD and BPD in relatives of children with ADHD + BPD compared to those with ADHD without BPD. The authors suggest that this pattern would not be expected with independent segregation of the two disorders.

 

1. Attention-Deficit Hyperactivity Disorder With Bipolar Disorder: A Familial Subtype? (Faraone, Biederman, Mennin, Wozniak, Spencer)

 

Objective: “To clarify the nosological status of children with ADHD who also satisfy diagnostic criteria for BPD.”

 

Method: Based on methodology of previous studies (see study B above), it was postulated that the nosological validity of ADHD+BPD could be addressed by examining the transmission of comorbid disorders in families. Data from preexisting genetic studies was used (Biederman et al. 1992, Faraone et al., 1995). Three groups were created. The first group was composed of ADHD probands. This group was later divided into two groups. One group had ADHD without BPD and other group had ADHD+BPD. The third group was composed of non-ADHD probands (the controls). Assessment for bipolar disorder in the probands and siblings was done by KSADS-E. Mothers and fathers of the children were assessed using the Structured Clinical Interview for DSM-III-R.

 

Results:

Proband

2. 11% of the ADHD proband met the criteria for BPD.

• Familial Risk Analysis (Overall risk)

1. Relatives of ADHD+BPD children had significantly higher rates of ADHD+BPD (12%) than either the ADHD (2%) or control (0%) probands.

 

2. In contrast, relatives of both the ADHD probands (14%) and ADHD+BPD (12%) probands had a significantly higher prevalence of ADHD w/o BPD than the control (3%).

 

3. The three groups did not differ in rates of BPD without ADHD; however, the age of onset of BPD (without ADHD) was significantly earlier in the relatives of the ADHD+BPD probands (11years) as compared to the ADHD probands (24 years) and controls (25 years).

• Cosegregation (based on assessment of ADHD+BPD proband relatives)

1. 55% of the relatives of the ADHD+BPD probands with ADHD also had BPD.

 

2. In contrast, only 5% of the relatives of the ADHD+BPD probands who did not have ADHD had BPD.

 

Author’s Conclusions: Familial Risks: Relatives of both the probands with ADHD (with or without BPD) are at significantly increased risk for ADHD as compared the controls. In contrast, only those relatives of the ADHD+BPD probands are at a significant increased risk of ADHD+ BPD.

 

Cosegregation: The findings that ADHD and BPD occurred more often together than would be expected by chance suggests that ADHD+BPD may be “familially distinct from other ADHD cases.” (i.e. one would not expect relatives of the ADHD+BPD probands with ADHD and without ADHD to have significantly different rates of bipolar disorder if ADHD and BPD segregated independently of each other).

 

1. Attention Deficit Hyperactivity disorder in Adolescent Mania (West, McElroy, Strakowski, Keck, McConville)

 

Objective: To examine the rate of ADHD in adolescents with BPD and to explore the potential effects of comorbid ADHD on the presentation of BPD.

 

Methods: The diagnosis of BPD was determined using the Structural Clinical Interview for DSM-III-R. ADHD was diagnosed based on past history and confirmed by interviews using the Schedule for Affective Disorder and Schizophrenia for School Age Children-Epidemiologic Version. Patients were rated weekly using the Young Mania Rating Scale and the Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale.

 

Results:

1. 57% of the patients who meet DSM-III-R criteria for mania or hypomania also met the criteria for ADHD. In all of these cases the onset of ADHD occurred prior to the onset of BP disorder. There was an average of 6 years between onsets of the two disorders.

 

2. Patients with both BP and ADHD had a higher mean total on the Young Mania Rating Scale.

 

Author’s Conclusion: The increased rate of ADHD in BPD patients found in this study is consistent with other studies suggesting comorbidity. In addition, the high mania rating score suggests that adolescents with comorbid ADHD and BPD may have a more varied symptomatic presentation.

 

3. It has also been suggested that the development of mania in children with ADHD may be a “secondary mania” resulting from organic pathology. Through various case presentations, Stasiek illustrated mania resulting from various drugs (including: corticosteroids, bronchodilators, etc). Metabolic disturbances, infection, and neoplasms were also cited as causing secondary mania (Stasiek, 1985).

 

 

IV Reference:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Test Revision. Washington, DC, American Psychiatric Association, 2000.

Carlson G (1990), Child and adolescent mania: diagnostic considerations. J child Psychol Psychiatry 31:331-342.

Faraone SV, Biederman J, Mennin D, Wozniak J, Spencer T (1997), Attention-deficit hyperactivity disorder with bipolar disorder: a familial subtype? J Am Acad Child Adolesc.Psychiatry, 36(10): 1378-1387.

Geller B, Luby J (1997), Child and Adolescent Bipolar Disorder: A Review of the Past 10 Years. J Am. Acad. Child Adolesc. Psychiatry 36(9): 1168-1176

Geller B, Sun K, Zimerman B, Luby J, Frazier J, Williams M (1995), Complex and rapid-cycling in bipolar children and adolescents: a preliminary study. J Affect Disord 34:259-268.

Stasiek, C & Zetin, M (1985), Organic manic disorders. Psychosomatics, 26, 394-402.

Weller E, Weller R, Fristad M (1995) Bipolar Disorder in Children: Misdiagnosis, Underdiagnosis, and Future Directions. J Am. Acad. Child Adolesc. Psychiatry 34(6):709-714

West. S, McElroy S, Strakowski S, Keck P, McConville B (1995), Attention Deficit Hyperactivity Disorder in Adolescent Mania. Am J Psychiatry 152:271-273.

Wozniak J, Biederman J, Mundy E, Mennin D, Faraone SV (1995), A pilot family study of childhood-onset mania. J Am Acad Child Adolesc Psychiatry 34: 1577-1583.