This document discusses differentiating between attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder in children. It poses four key questions about whether they are separate illnesses, overlapping syndromes, coexistent symptoms, or if ADHD is a warning sign of bipolar disorder. It then provides background on the history and diagnostic criteria of ADHD, as well as statistics on its prevalence. It also discusses the challenges of diagnosing pediatric bipolar disorder and lists common developmental manifestations of manic symptoms in children. The document notes that ADHD and bipolar disorder are highly comorbid conditions and explores some ways to differentiate between the two.
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ADHD Bipolar Disorder
1. Attention-Deficit/Hyperactivity Disorder vs.
Bipolar Disease in the Pediatric Population
Richard G Petty MD, MSc, MRCP(UK),
MRCPsych,
Promedica Research Center,
Georgia State University College of Health
Sciences,
Loganville, Georgia,
USA
rpettyus@aol.com
Sunday, July 26, 2009
2. Disclosure
Richard G. Petty, MD, MSc, MRCP(UK), MRCPsych
Consultant
AstraZeneca; Bristol Myers Squibb; Eli Lilly and Company;
Janssen Pharmaceuticals
Speaker’s Bureau
Abbott Laboratories; AstraZeneca; Avanir Pharmaceuticals;
Janssen Pharmaceuticals
Grant Support
British Diabetic Association; Bristol Myers Squibb; British Heart
Foundation; Du Pont Merck, Inc.; Eli Lilly and Company; Janssen;
Medical Research Council (UK); National Institute of Mental
Health; Pfizer
Dr. Petty’s presentation will include the discussion of off-
label, experimental, and/or investigational use of drugs or
devices
Sunday, July 26, 2009
3. Attention-Deficit/Hyperactivity Disorder and
Bipolar Disorder
There are four key questions:
Are they two separate illnesses?
Are they two overlapping syndromes?
Are they sets of coexistent symptoms?
How often is Attention-Deficit/Hyperactivity Disorder an
early symptom or warning sign of impending bipolar
disorder?
Do these questions matter?
Sunday, July 26, 2009
4. History of Attention-Deficit/Hyperactivity
Disorder (ADHD)
• Mid-1800s: Minimal Brain Damage
• 1902 Defects in moral character
• 1934 Organically driven
• 1940 Minimal Brain Syndrome
• 1957 Hyperkinetic Impulse Disorder
• 1960 Minimal Brain Dysfunction (MBD)
• 1968 Hyperkinetic Reaction of Childhood (DSM II)
• 1980 Attention-Deficit Disorder - ADD (DSM III) with-
hyperactivity without-hyperactivity residual type
• 1994-present: Attention-Deficit/Hyperactivity Disorder:
• 314.01: ADHD, Combined Type
314.00: ADHD, Predominantly Inattentive type
314.01: ADHD, Predominantly Hyperactive-Impulsive Type
Sunday, July 26, 2009
5. ADHD Statistics
• 3-5% of all U.S. school-age children are
estimated to have this disorder
• 5-10% of the entire U.S. population
• Males are 3 to 6 times more likely to have
diagnosed ADHD than are females
• At least 50% of ADHD sufferers have another
diagnosable mental disorder
Sunday, July 26, 2009
6. Diagnostic Features
Persistent pattern of:
Inattention
Hyperactivity
Impulsivity
Sunday, July 26, 2009
7. Components of Attention
Arousal and alertness
External or receptive attention: sensory processing and
interpretation
Internal or reflective attention
Processing attention or selective attention
Focus
Filtering
Inhibition of sensation
External or expressive attention
Working memory
Sunday, July 26, 2009
8. Diagnosing ADHD: DSM-IV
Inattentiveness:
Has a minimum of 6
symptoms regularly for the
past six months
Symptoms are present at
abnormal levels for stage of
development
Sunday, July 26, 2009
9. Diagnosing ADHD: DSM-IV
• Lacks attention to detail;
makes careless mistakes
Inattentiveness: • Has difficulty sustaining
attention
• Doesn’t seem to listen
Has a minimum of 6
• Fails to follow through/fails to
symptoms regularly for the finish projects
past six months
• Has difficulty organizing
tasks
Symptoms are present at • Avoids tasks requiring
abnormal levels for stage of mental effort
development • Often loses items necessary
for completing a task
• Easily distracted
• Is forgetful in daily activities
Sunday, July 26, 2009
10. Diagnosing ADHD: DSM-IV
• Hyperactivity/
Impulsivity:
Has a minimum of 6
symptoms regularly for the
past six months.
Symptoms are present at
abnormal levels for stage of
development
Sunday, July 26, 2009
11. Diagnosing ADHD: DSM-IV
• Fidgets or squirms
excessively
• Hyperactivity/ • Leaves seat when
Impulsivity: inappropriate
• Runs about/climbs
extensively when
Has a minimum of 6 inappropriate
symptoms regularly for the • Has difficulty playing quietly
past six months. • Often “on the go” or “driven
by a motor”
Symptoms are present at • Talks excessively
abnormal levels for stage of • Blurts out answers before
development question is finished
• Cannot await turn
• Interrupts or intrudes on
others
Sunday, July 26, 2009
12. Diagnosing ADHD: DSM-IV
• Symptoms causing impairment
Additional present before age 7
Criteria: • Impairment from symptoms
occurs in two or more settings
• Clear evidence of significant
impairment (social, academic,
etc.)
• Symptoms not better accounted
for by another mental disorder
Sunday, July 26, 2009
13. Problems of Diagnosis
Subjectivity of Criteria
Inconsistent evaluations--presence of symptoms
usually given by teacher or parent
Studies have shown that the number of
diagnosed cases of ADHD decreased 80% when
observations of parent, teacher and physician
were used rather than just one source
Symptoms in females more subtle---leads to
under-diagnosis
Sunday, July 26, 2009
14. ADHD and the Brain
Diminished arousal of
some regions of the
nervous system
Decreased blood flow to
prefrontal cortex and
pathways connecting to
limbic system (caudate
nucleus and striatum)
PET scan shows
decreased glucose
metabolism throughout Comparison of normal brain (left) and
brain brain of ADHD patient.
Sunday, July 26, 2009
15. ADHD and the Brain II
Similarities of ADHD symptoms to those from
injuries and lesions of frontal lobe and prefrontal
cortex
MRI scans of ADHD patients consistently show:
• Smaller anterior right frontal lobe
abnormal development in the frontal and striatal regions
• Significantly smaller splenium of corpus callosum
decreased communication and processing of information
between hemispheres
• Smaller caudate nucleus
Sunday, July 26, 2009
16. What Causes ADHD?
Underlying cause of these differences is still
unknown; there is much conflicting data between
studies
Strong evidence of genetic component
Predominant theory: catecholamine neurotransmitter
dysfunction or imbalance
Decreased dopamine and/or norepinephrine uptake in brain
Theory supported by positive response to stimulant
treatment
Recent study in mice indicates possible lack of
serotonin as a factor
Diet
Constant over-stimulation
Sunday, July 26, 2009
18. Ch
Academic ildr
en
limitations
Occupational/ Relationships
vocational
Adults
Legal
difficulties ADHD Low self
esteem
Motor vehicle
accidents Injuries
Smoking and
substance abuse
Adolescents
Sunday, July 26, 2009
19. ADHD: Impact of No Treatment or
Under-Treatment
Health Care
System
Family
3-5x increase in Parental
50% increased in bicycle accidents1 Patient Divorce
or Separation11,12
33% increase in ER visits2
2-4 x increase in Sibling Fights13
2-4 x more motor
vehicle accidents3-5
Society Employer
School & Occupation Increased Parental
Substance Use Disorders:
46% Expelled6
2 X Risk8 Absenteeism14
35% Drop Out6 Earlier Onset9 and reduced
Lower Occupational Status7 Less Likely to Quit Productivity14
in Adulthood10
1. DiScala et al., 1998. 6. Barkley, et al., 1990. 9. Pomerleau et al., 1995. 12. Brown & Pacini, 1989.
2. Liebson et al., 2001. 7. Mannuzza et al., 1997. 10. Wilens et al., 1995. 13. Mash & Johnston, 1983.
3. NHTSA, 1997. 8. Biederman et al., 1997. 11. Barkley, Fischer et al., 1991. 14. Noe et al., 1999.
4-5. Barkley et al., 1993; 1996.
Sunday, July 26, 2009
21. Difficulties in Diagnosing Pediatric Bipolar
Disorder
Variability in clinical presentation
Severity, phase of the illness (depressed, manic,
mixed, rapid cycling); and subtype of bipolar disorder
Highly comorbid with other psychiatric disorders
Effects of child’s development in symptom expression
Child’s physical and behavioral problems may be
expressions of her or his symptoms
Effects of medications
Context where the bipolar disorder is developing
Sunday, July 26, 2009
22. Developmental Manifestations of Manic Symptoms
in Children
Elation/euphoria
Giggling uncontrollably in class while peers are calm;
laughing hysterically when talking about killing others
Dancing and laughing at home while telling parents’ they
are “suspended”
Finds everything funny & they don’t know why
Decreased need for sleep
Up at 2 AM rearranging furniture, cleaning, then awake at
6 AM dressed and ready for school
Child awake at 4 AM during summer vacation
Geller et al., American Journal of Psychiatry, 2002; 159: 927-933
Sunday, July 26, 2009
23. Developmental Manifestations of Manic
Symptoms in Children (continued)
Grandiosity
Telling principal to “shut up” and listen because the principal is
the child’s “slave”; demanding that teacher be fired for stupidity
Child stealing go-kart because he felt rules did not apply to him
(acute onset of conduct d/o)
Child believing he/she is a superhero & tries to fly
Child spends evenings “practicing” when they become
president, despite failing in school
Hypersexuality – drawing or preoccupied with pictures of naked
people; inappropriate kissing, touching of others breasts/buttocks; 1-900-
sex lines; sexually vulgar language; sending notes propositioning peers
Sunday, July 26, 2009
34. Attention Deficit Disorder, Pediatric Bipolar
Disorder and Neurobehavioral Disorders
ALL START IN CHILDHOOD
Attention Deficit Hyperactivity Disorder
ADHD starts before age seven
Pediatric Bipolar Disorder
Starts before puberty
Neurobehavioral Disorders
Often prenatal or perinatal in origin
Initial symptoms start in early childhood
Sunday, July 26, 2009
35. Attention-Deficit/Hyperactivity Disorder
Children with Attention-Deficit/Hyperactivity
Disorder are NOT more active in play
ONLY when they are asked to stop and sit still
Therefore, we see a diminished:
Ability to INHIBIT activity
Therefore: impulsive, hyperactive (immature)
Ability to INHIBIT response to distractions
Therefore: inattentive (not age appropriate)
The brain’s “brake” is not working well
Sunday, July 26, 2009
36. AD/HD - Co-existing Conditions:
Depression
35 % of individuals with AD/HD will have depression
50
45
40
35
30 Children
25
20 Adults
15
10
5
0
Sunday, July 26, 2009
37. AD/HD - Co-existing Conditions:
Mania or Bipolar Disorder
20% of individuals with AD/HD may manifest
bipolar disorder
May have moods that change very rapidly,
seemingly for no reason
Sunday, July 26, 2009
38. AD/HD - Co-existing Conditions: Anxiety
Disorders
35% of individuals with AD/HD will have anxiety.
40
35
30
25 Children
20
Adults
15
10
5
0
Sunday, July 26, 2009
39. Bipolar Disorder - Differential Diagnoses
Normal moodiness and behaviors
Recurrent explosive, aggressive, and irritable
behaviors: Bipolar vs. unipolar recurrent agitated
MDD vs. ADHD + ODD
Asperger’s Disorder
ADHD vs. Bipolar
Abrupt onset of “ADHD”
Late onset “ADHD”
Intermittent “ADHD”
Intermittent worsening of the ADHD symptoms
( “tolerance” to the stimulants)
In adolescents: Borderline Personality Disorder
Sunday, July 26, 2009
40. Things That Look Like ADHD
Depression Learning disabilities
Anxiety Parenting problems
Hearing problems Substance use
Visual problems Medication side-effects
Seizure disorder Lead poisoning
Oppositional defiant
disorder
Autism
Sunday, July 26, 2009
41. Diagnostic Overlap between Mania & ADHD
DSM-IV Mania ADHD
Elevated, expansive mood No
Irritability Commonly associated
Inflated self-esteem / grandiosity No
Decreased need for sleep Can be present
More talkative / pressured speech DSM-IV Criteria
Flight of Ideas or racing thoughts No
Hyperactivity / goal-directed activity DSM-IV Criteria
Pleasurable activities with high risk
Commonly associated
…for painful consequences
Distractibility DSM-IV Criteria
Sunday, July 26, 2009
42. Pediatric Bipolar Disorder
Bipolar (Manic Depressive) Disorder
Pediatric Mania
Hyperactive even in play
• ADHD normal during play
Racing thoughts, rapid speech
• ADHD shows normal rate of cognition and speech
Little need to sleep
• ADHD children may be too hyperactive to fall asleep
• But their need for sleep is otherwise normal
Euphoria, grandiosity - unique to Mania
Geller et al., American Journal of Psychiatry, 2002; 159: 927-933
Sunday, July 26, 2009
43. Attention-Deficit/Hyperactivity Disorder
versus Mania
Attention Deficit Hyperactivity Disorder = Poor “brakes”
Cannot stop - in age appropriate manner
Mania = Too much “acceleration”
Brain is racing too fast
Both may show:
Hyperactivity, distractibility, irritability
Mania shows severe mood swings:
Elation, grandiosity, racing thoughts/speech
Sunday, July 26, 2009
44. Keys to Differentiating Bipolar Disorder and Attention Deficit
Disorder
Bipolar Disorder ADD/ADHD
Most common onset ages 15-19 Present by K/G1 or Earlier
Family history of attentional problems but mood
Family history of mood disorder
disorders less commonly
Family history of alcohol or substance abuse
Family history of alcohol or substance abuse
less common
Fluctuating moods Fluctuating attention
Discrete mood episodes Chronic condition
Seasonality of symptoms No seasonal component
Premenstrual exacerbation of attentional
Hormonal exacerbation of mood disorders
problems
Daily variation in mood and activity Relatively fixed mood and activity level in the
Flight of Ideas or racing thoughts Accelerated thinking
Poor response to antidepressants Equivocal response to antidepressants
Symptoms often exacerbated by psychostimulants Symptoms usually improved by
psychostimulants
Sunday, July 26, 2009
45. Children with Bipolar Disorder and Elation/
Grandiosity (n=93) vs. ADHD (n=81)
100
75
50
25
0
1 2 3 4 5 6 7 8 9
le
ed
ed
le
se
nt
ctib
y
ch
Ne
at
tab
erg
me
t
dio
igh
El
ee
tra
ep
dg
Irri
an
En
Fl
Sp
Dis
g/
Sle
Gr
Ju
cin
Ra
=BPD
Geller et al., American Journal of Psychiatry, 2002; 159: 927-933
Sunday, July 26, 2009
46. Irritable Neurobehavioral Disordered
Children
Irritability may be based on disorders of brain chemistry:
Attention Deficit Hyperactivity Disorder, Bipolar
Disorder, Schizophrenia, etc.
Or it may be a child with early brain damage from:
Drugs or alcohol used in pregnancy
Difficult or premature delivery
Very early traumatic brain injury
Genetic diseases
Epileptiform disorders
Sunday, July 26, 2009
47. Impulsive/Irritable
Irritability = short fuse
Early onset/persistent tantrums
Impulsive behavior
Impulsive aggression
These behaviors are NOT premeditated
Irritable behaviors are not planned
Quick/hot temper = Poor impulse control and too much
emotion
Differs from conduct disorders, some psychosis and
Psychopathy:
In cold blood, premeditated, too little emotion
Sunday, July 26, 2009
51. Assessments
Comprehensive clinical evaluation Check for IQ,
learning disabilities
Check for other diagnoses
Rule out Bipolar disorder, Neurocognitive
problems and other disorders
ADHD rating scales
Conners Scales for Teachers
Neuropsychological testing
Continuous Performance Test (CPT)
Sunday, July 26, 2009
52. The Pharmacological Treatment of ADHD:
Stimulants and Others
Methylphenidate: Ritalin: 5-60mg; Concerta 18-81mg/day
Dextroamphetamine: Dexidrine SR: 5-15mg
Adderall XR: 4 amphetamine salts: 10-30mg
Pemoline: Cylert: 37.5mg/day, increase up to 75mg
Atomoxetine: Strattera (non-stimulant): 80-120mg
Others:
Modafinil: Provigil: 300mg
Buproprion: dopamine and norepinephrine reuptake inhibitor
Clonidine: α-adrenoceptor agonists: 0.1mg t.i.d.
(Guanfacine {Tenex}): α-adrenoceptor agonists: 1-3mg q.d.
Sunday, July 26, 2009
53. ADHD: Treatment Types
Medications: Essential to explain to the child - and adults -
that treatment must be year-round
Integrated medical approaches:
Nutrition
Food additives
Herbs and supplements including fish oils
Homeopathy
Acupuncture
Parent Training – Positive Discipline
BIP (Behavior Intervention Plan)
Structure – routines, schedules
School supports
Sunday, July 26, 2009
55. Treatment of Bipolar Disorder in Children
Acute
Maintenance (prevention of relapses and
recurrences)
Treatment of mania, depression, rapid
cycling, mixed episodes, and sometimes
psychosis
Tools:
Medications
Psychotherapy
Life style management
Sunday, July 26, 2009
57. Pharmacological Treatment
Mood Stabilizers
Lithium
Anticonvulsants
Valproate (Depakote); carbamazepine (Tegretol);
oxcarbamazepine (Tryleptal); lamotrigine (Lamictal) etc.
New antipsychotics
Risperidone (Risperdal), olanzapine (Zyprexa);
quetiapine (Seroquel), ziprasidone (Geodon),
aripripazole (Abilify) etc.
Antidepressants
Selective Serotonin Reuptake Inhibitors
Venlafaxine (Effexor), bupropion (Wellbutrim) etc.
Others: benzodiazepines, fish oils etc.
N.B. None is indicated for use in people under the age of 18
Sunday, July 26, 2009
58. Bipolar Disorder – Pharmacological
Treatment (Cont’)
• Very few studies in youth - mostly open label
• Response to acute treatment with mood
stabilizers (lithium, valproate (VPA),
carbamazepine (CBZ) approx. 40%-80%
• Small study showed that valproate + quetiapine
was better than valproate + placebo for children
with mania
• Open studies suggest that the “atypicals” alone or
in combination may be efficacious
• May need treatment with multiple medications
Sunday, July 26, 2009
59. Psychosocial Treatments
Family Focus Therapy (FFT)
Cognitive Behavior Therapy (CBT)
Interpersonal Psychotherapy (IPT)
Interpersonal and Social Rhythms Therapy
(IPSRT)
Sunday, July 26, 2009
60. Why Treat Adolescent Bipolar Patients with
Adjunctive Family Psychoeducation?
Family psychoeducation is a powerful adjunct to
pharmacotherapy for adult bipolar patients
Family factors are correlated with the course of recurrent
mood disorders in adults and children
Early-onset mood and behavioral disturbances are
associated with a high familial loading for major affective
disorder
Mood stabilizers can be difficult to dispense safely to
adolescents living in chaotic family environments
Sunday, July 26, 2009
61. Family Expressed Emotion Status as a Predictor of
9-Month Clinical Outcome
15
Number of Patients
11
8
4
0
Low EE (7/13) High EE (9/10)
No Relapse Relapse
North
χ2(1) = 3.82, p=.05
Miklowitz DJ , et al. Arch Gen Psychiatry, 1988;45(3):225-231
Sunday, July 26, 2009
64. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
Sunday, July 26, 2009
65. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
With many causes
Sunday, July 26, 2009
66. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
With many causes
Often genetic (e.g. DAT-1, DRD2, D4 genes)
Sunday, July 26, 2009
67. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
With many causes
Often genetic (e.g. DAT-1, DRD2, D4 genes)
Can produce serious life distress
Sunday, July 26, 2009
68. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
With many causes
Often genetic (e.g. DAT-1, DRD2, D4 genes)
Can produce serious life distress
Learning, behavior, social, teen safety
Sunday, July 26, 2009
69. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
With many causes
Often genetic (e.g. DAT-1, DRD2, D4 genes)
Can produce serious life distress
Learning, behavior, social, teen safety
Goal is to create resilience:
Sunday, July 26, 2009
70. Summary 1: ADHD
Attention Deficit Hyperactivity Disorder
A common childhood disorder
With many causes
Often genetic (e.g. DAT-1, DRD2, D4 genes)
Can produce serious life distress
Learning, behavior, social, teen safety
Goal is to create resilience:
Positive discipline, structure, medications
Sunday, July 26, 2009
72. Summary 2: Bipolar Disorder
• BP disorder in youth is a chronic and difficult to treat
illness that conveys high morbidity (e.g., behavior
problems, substance abuse), poor psychosocial
functioning, psychosis, and risk for suicide
Sunday, July 26, 2009
73. Summary 2: Bipolar Disorder
• BP disorder in youth is a chronic and difficult to treat
illness that conveys high morbidity (e.g., behavior
problems, substance abuse), poor psychosocial
functioning, psychosis, and risk for suicide
• Youth with BP usually have mixed and rapid cycling
patterns that are the types carrying the worst prognosis
and are more difficult to treat
Sunday, July 26, 2009
74. Summary 2: Bipolar Disorder
• BP disorder in youth is a chronic and difficult to treat
illness that conveys high morbidity (e.g., behavior
problems, substance abuse), poor psychosocial
functioning, psychosis, and risk for suicide
• Youth with BP usually have mixed and rapid cycling
patterns that are the types carrying the worst prognosis
and are more difficult to treat
• BP is highly comorbid with other psychiatric disorders
that require identification and treatment
Sunday, July 26, 2009
75. Summary 2: Bipolar Disorder
• BP disorder in youth is a chronic and difficult to treat
illness that conveys high morbidity (e.g., behavior
problems, substance abuse), poor psychosocial
functioning, psychosis, and risk for suicide
• Youth with BP usually have mixed and rapid cycling
patterns that are the types carrying the worst prognosis
and are more difficult to treat
• BP is highly comorbid with other psychiatric disorders
that require identification and treatment
• The diagnosis of BP may be difficult and requires
longitudinal follow-up
Sunday, July 26, 2009
76. Summary 3
The treatment of both ADHD and bipolar disorder
requires four attention to four factors:
Physical:
Appropriate medications
Nutrition
Environmental factors
Psychological
Social
Spiritual
Sunday, July 26, 2009