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 Issues in Diagnosis of Pediatric Bipolar Disorder versus ADHD

 By Beatriz Rodriguez, Office Intern and Ernest J. Bordini, Ph.D., Executive Director, 

 Clinical Psychology Associates of N. Central Florida    Gainesville - Ocala 

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A rising topic of discussion in the pediatric psychiatry community is the  differential diagnosis and comorbidity between Attention Deficit Hyperactivity Disorder  (ADHD), a relatively common childhood neurodevelopmental disorder, and pediatric Bipolar Disorder, a much rarer condition.  While there is as much of a 70% overlap in symptoms, important differences in  the nature, severity, and course of symptoms are essential to diagnostic assessment.  Below is a discussion of differential diagnosis between these disorders as well as a new and perhaps controversial diagnosis of Disruptive Mood Dysregulation Disorder (DMDD), introduced due to concerns that pediatric bipolar was being over-diagnosed.
Family history of mood disorders is a risk factor for bipolar spectrum disorder  (Hawton et al., 2005).  However, there are factors other than genetics that play a role in italian finger puppets - all rights reserved clinical psychology associates of north central floridaindividual and family risk for bipolar.  While full blow bipolar disorder is rare in adults (approximately 1%, to 4-5% for bipolar spectrum), estimates of risks for children with one bipolar parent range from 15-30% and slightly more than double that when both parents are diagnosed as bipolar (Singh, 2008). 
An important psychosocial risk factor is a history of abuse. Studies have found that child abuse victims and adult abuse survivors have a greater  rate of mood disorders.  Children who have been abused also often exhibit more difficulties with concentrating relative to their peers (Briere and Elliott, 1994). Many of these victims may be diagnosed as bipolar and/or ADHD by the time they reach adulthood.
Attention Deficit Hyperactivity Disorder is one of the most prevalent child and adolescent mental health disorders, with an onset age typically before 12. The criterion for DSM – 5 diagnosis for ADHD in children requires at least 6 of the symptoms of ADHD, while young adults of 17 years and older need to meet 5 of the symptoms listed (DSM – 5, American Psychiatric Association, 2013).
There are two symptom categories for ADHD. These include inattention and hyperactivity/impulsivity. Some of  the symptoms for inattention include failing to give close attention to details, having trouble with maintaining attention on tasks or play activities, not following through on instructions, being reluctant to do tasks that require mental effort over a long period of time, and being forgetful about daily activities.
One of the first requirements for the subcategory of hyperactivity and impulsivity is that the symptoms must have manifested for at least 6 months or to an extent that it is considered disruptive, or inappropriate for the individual’s development. A few of these symptoms include fidgeting hands, or tapping their hands and feet, squirming in their seat, running or climbing in situations where it is not appropriate, blurting out answers before a question has been completed, or rudely interrupting others while talking.
There are three types of ADHD that can be diagnosed: combined presentation, predominantly inattentive presentation, and predominantly hyperactive-impulsive presentation (Zead, Hifzi, Muhammad, and Imran, 2015). Some patients show ADHD symptoms but are mostly either hyperactive-impulsive or inattentive and hence they are given the appropriate diagnosis according to their condition.
Diagnosis of Bipolar Disorder is considered in the context of episodic manic symptoms and depression. According to DSM-5 diagnostic criteria, there are 4 subtypes: Bipolar I, Bipolar II, Bipolar Disorder Not Otherwise Specified (BP-NOS), and Cyclothymia. These conditions differ in terms of both manic and depressive intensity and duration. When it comes to hypomania, patients are required to demonstrate symptoms for at least 4 days, whereas patients with manic symptoms are required to exhibit symptoms every day for at least a week. Hypomanic episodes differ from manic episodes in terms of intensity of symptoms, and may be subjectively less distressing to the individual than is often seen in more sustained and dramatic manic episodes.
Adult manic episodes can be marked by periods of euphoria, delusions, and over-activity. Pediatric manic episodes are very similar but the diagnostic criteria note they can range from brief, tantrum-like storms lasting for minutes or hours (not necessarily uncommon in ADHD) to episodes that persist for days or months. An individual may experience periods of manic, hypomanic, both, or unspecified symptoms. Unspecified symptoms are symptoms that closely resemble those suffered during a manic or hypomanic episode but cannot be diagnosed under these categories. Such unspecified symptoms exist for most mental disorders.  Hypomanic symptoms tend to be less severe than manic but a patient may suffer from both manic and hypomanic episodes and symptoms. Some of the symptoms present in both include inflated self-esteem, decreased need for sleep, flight of ideas or subjective experience that thoughts are racing, and excessive involvement in activities that have a high potential for painful consequences. Given overlapping symptoms, it is would be very easy to misdiagnose manic episodes as hypomanic and vice-versa.  This is where judgment about symptom intensity becomes more important.
According to DSM – 5, the mood disturbance during a manic episode must be severe enough to cause marked impairment in social or occupational functioning. Certainly, while not always the case, bipolar symptoms can become so severe that patients may be hospitalized to prevent harm to self or others.  Some manic episodes may involve delusions, breaks with reality or other psychotic features.  These types of severe episodes are not likely to be confused with ADHD or with milder hypomania. With hypomania, the disturbance in behavior and the changes in functioning may be less disruptive or recognized by the individual, and often, as with ADHD, the behaviors may be identified as more problematic by family, teachers, or coworkers.   
There is controversy regarding diagnosis of bipolar disorder in children (Faedda et al., 1995). It is important to note diagnosis of Pediatric Bipolar Disorder requires diagnosis of at least one depressive episode. Manic episodes in children are usually characterized by frequent and short periods of “intense mood lability and irritability”.  These episodes and symptoms typically tend to last for a longer period of time for adults (Kowatch, Sethuraman, Hume, Kromelis, and Weingberg, 2003). Given that  younger children generally have less developed impulse control and cognitive modulation of affect, and ADHD children have deficiencies in frustration tolerance and self-regulation, this increases the risk of over diagnosis if the pattern and context of these symptoms is not considered.
Also complicating the diagnostic differential is the addition of a new, and somewhat controversial DSM-5 diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). It is characterized by chronic, persistent irritability in children as well as low frustration tolerance and difficulties in emotional regulation (Gilea and O’Neil, 2014). DMDD was included in the DSM-5 to address the potential overdiagnosis of pediatric bipolar disorder and it specifically requires the displayed irritability to be non-episodic and frequent.
A behavioral pattern for childhood mania may include insomnia, irritability, and euphoria, flight of ideas, pressured speech and hyperactivity (Faedda et al., 1995). However, these individual symptoms are often encountered in children with ADHD.  Singh (2008) noted "Unfortunately it is almost impossible to differentiate “pressure to keep talking” ([hypo] mania) and “often talks excessively” (ADHD), psychomotor agitation ([hypo] mania) and “often runs about or climbs excessively” (ADHD), and distractibility (both [hypo] mania and ADHD)".
lacross boys  all rights reserved clinical psycholog associates of north central floridaChildren with Bipolar Disorder tend to show higher and more sustained levels of irritability.  In bipolar children symptoms usually occur during distinct manic or hypomanic episodes in which the child may be euphoric or have an elevated mood. Children diagnosed as bipolar tend to demonstrate more intense behavioral episodes.  Changes in mood with no apparent reason can occur multiple times a day. Staton, Volness, and Beatty (2008) also describe a pattern of symptoms marked by frequent mood changes and “ultradian” cycling, in which the child interchanges between mania and depression every day.  Children with ADHD often calm after about 20 to 30 minutes, whereas children with bipolar disorder may have anger outburst that can last for hours (Popper et al., 1989). 
While it is snot uncommon for children with anxiety, or those at certain ages to have nightmares, children with Bipolar Disorder tend to have dreams that can be very vivid and violent.  This may interrupt sleep or cause them to become fearful of bedtime (Popper et al., 1989). Children with ADHD also may have difficulties falling asleep given their hyperactivity, but they do not usually report great difficulty staying asleep. 
ADHD and pediatric Bipolar Disorder children share many symptoms such as impulsivity, insomnia, hyperactivity, and inattention which can interfere with educational and occupational functioning.   Given these symptoms it is not surprising both groups could have academic difficulties.  However, ADHD children have a higher risk  than bipolar children for formal diagnosis of learning disorder. Children with bipolar disorder are more prone to exhibit more pronounced motivational changes in their school performance versus a history of learning disabilities (Popper et al., 1989).These
Bipolar disorder and ADHD both can co-exist with conduct disorder and oppositional-defiant disorder (Popper et al., 1989). However, the temper tantrums often seen in Conduct disorder are instrumental rather than unpredictable, designed to punish efforts at correcting behavior.  Singh (2008) noted conduct disorder often progresses from less to more severe rule breaking, but mania tends to presents as abrupt onset of impulsive behavior. 
Careful attention to the episodic course of symptoms, context, and affective symptoms is needed to avoid misdiagnosis or over-diagnosis of pediatric Bipolar Disorder in ADHD children.  Singh( 2008),summarized research noted that symptoms which tend to be more associated with hypomania or mania such as grandiosity, elated mood, flight of ideas, decreased need for sleep, hypersexuality, and increased goal-directed activity are helpful for differential diagnosis,
Careful clinical interview of children and parents, obtaining information from teachers and other observers, medical work up, and formal psychological testing are often required for accurate differential.  Pediatric neuropsychological assessments involve in depth examinations of diagnostic differential, and co-existing disorders with appropriate age norms and standardized measures.  A formal tool for assessing childhood bipolar disorder is the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), first introduced in 1978.  This measure includes direct interviews with children about symptoms, including pre-pubescent manifestations of Major Depressive Disorder (Geller et al., 1998). In pediatric cases, such testing is usually done either with a child psychologist, a pediatric neuropsychologist, or a child psychiatrist.  Other tools have also been suggested by Singh (2008). 
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn. Washington: APA, 2013
Briere, J., & Elliott, D. (1994). Immediate and Long-Term Impacts of Child Sexual Abuse. The Future of Children,4(2), 54-69.
Faedda, L., Baldessarini, R. J., Suppes, T., Tondo, L., Becker, I., & Lipschitz, D. S. (1995).
Pediatric-Onset Bipolar Disorder: A Neglected Clinical and Public Health Problem Gianni. Harvard Review of Psychiatry, 3(4), 171-195.
Geller, B., Warner, K., Williams, M., & Zimerman, B. (1998). Prepubertal and young adolescent bipolarity versus ADHD: Assessment and validity using the WASH-U-KSADS, CBCL and TRF. Journal of Affective Disorders,51, 93-100.
Gilea, B. L., & O’Neill, R. M. (2014). Disruptive Mood Dysregulation Disorder. American Counseling Association Practice Briefs.
Hawton, Keith, Lesley Sutton, Camilla Haw, Julia Sinclair, and Louise Harriss. "Suicide and Attempted Suicide in Bipolar Disorder." The Journal of Clinical Psychiatry J. Clin. Psychiatry 66, no. 6 (2005): 693-704.
Kowatch, R. A., Sethuraman, G., Hume, J. H., Kromelis, M., & Weinberg, W. A. (2003). Combination pharmacotherapy in children and adolescents with bipolar disorder. Biological Psychiatry, 53(11), 978-984.
Popper, C. (1989). Diagnosing bipolar vs. ADHD. Newsletter of the Academy of Child and Adolescent Psychiatry, 5(6).
Said, Z., Huzair, H., Helal, M. N., & Mushtaq, I. (2015). Attention deficit hyperactivity disorder (ADHD) in children and adolescents. Progress in Neurology and
Psychiatry, 19(3), 16-23.
Staton, D., Volness, L. J., & Beatty, W. W. (2008). Diagnosis and classification of pediatric Bipolar Disorder. Journal of Affective Disorders, 105(1), 205-212.
Published 11/21/15    Edited by Ernest J. Bordini, Ph.D. updated 8/01/23

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