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Is It ADHD or Bipolar Disorder?

Children with bipolar disorder are often misdiagnosed as having ADHD, and ADHD medication won't help. Sometimes, children suffer from both.

WebMD Feature

Reviewed By Brunilda Nazario

When Alex Raeburn was in the fourth grade, he started having discipline problems and occasional outbursts in school. Toward the end of his fifth grade year, he stormed out of the classroom, broke the glass face of a hall clock, then left the school building entirely. The incident landed him in the psychiatric ward of a hospital where he underwent testing, but he left without a diagnosis.

Alex's problems continued, so his parents took him to see a psychiatrist who had been recommended by his school's psychologist. "This doctor talked to my wife and I for 15 minutes, then to Alex for 15 minutes, diagnosed him with ADHD (attention deficit hyperactivity disorder) and put him on Ritalin," says Paul Raeburn, who wrote a book about his son's experiences entitled Acquainted with the Night. When there was no improvement after a few weeks on the medication, the doctor suggested increasing Alex's dose.

"After we increased the dose, Alex became completely out of control, very volatile and angry," Raeburn tells WebMD. "He threatened to run out of the house and not come back, so we had to hospitalize him again."

It was during this hospital stay that bipolar disorder was first suggested as a possible diagnosis instead of ADHD. Eventually, it was confirmed that Alex indeed suffered from bipolar disorder and that the Ritalin had most likely triggered his violent episode.

Because ADHD and bipolar disorder do share some symptoms and sometimes coexist, children like Alex are commonly misdiagnosed. ADHD is a more common condition in children and often the first thing a doctor thinks of.

"One problem is that there are not many child psychiatrists in this country, so parents take their child to a pediatrician, who just isn't equipped to do a comprehensive assessment, says J. Kim Penberthy, PhD, a professor in the department of psychiatric medicine at the University of Virginia. "Instead, a quick and dirty job of diagnosing is done."

According to the National Institute of Mental Health, bipolar disorder is difficult to recognize and diagnose in youths because it does not fit typical symptoms seen for adults.

Research done by Joseph Biederman, MD, a child psychiatrist and expert in bipolar disorder in children, estimates the frequency of ADHD in school-aged kids at 3%-5%. The frequency of bipolar disorder in the same group is estimated to be less than half of 1%. Most of the children diagnosed with bipolar disorder also meet the criteria for ADHD, while only about one in five with ADHD meet bipolar disorder criteria.

Some experts believe that ADHD is overdiagnosed, and while bipolar disorder is relatively rare in children, it tends to be underdiagnosed. This could be because bipolar disorder typically surfaces in adolescence or early adulthood, and it is much less black-and-white in terms of how it manifests in children.

Current research suggests that there may in fact be a third, separate disorder that is somewhere in between the two.

Symptoms present in both ADHD and bipolar disorder include impulsivity, inattention, and hyperactivity, and both disorders seem to be inheritable.

But there are many differences, the biggest being that bipolar disorder is primarily a mood disorder, while ADHD affects attention and behavior. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of ADHD, conduct disorder, oppositional defiant disorder, or other types of mental disorders.

A few other key ways in which they differ include:

How anger manifests itself. Though both ADHD and bipolar disorder have an anger component, the tantrums of a kid with ADHD are usually born out of frustration or overstimulation; any destructiveness is also unintentional and a result of carelessness.

With a bipolar child, anger is explosive and extreme and usually triggered when a parent or other authority figure attempts to set limits; destructiveness is often intentional. A kid with bipolar disorder can sustain his rage for as long as two hours, whereas one with ADHD can usually be calmed down within 20-30 minutes.

Whether or not psychosis is present. "With bipolar disorder, a large number of kids have psychosis, meaning thoughts and behaviors not based in reality," says Stephanie Hamarman, MD. "For example, a child might really believe he has superpowers and can fly. ADHD kids do not exhibit psychosis." Hamarman is chief of psychiatry at the Stanley Lamm Institute of Long Island College Hospital in Brooklyn, N.Y.