Is It ADHD or Bipolar Disorder?

Last Editorial Review: 1/31/2005

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.

How consistent the behaviors are. ADHD symptoms tend to be chronic, while bipolar disorder is generally more episodic. ADHD tends to improve over time; bipolar disorder often gets worse, especially if proper treatment is delayed.

Treating these illnesses routinely starts with mood-stabilizing medications. Studies are looking into the effectiveness of other forms of therapy like psychotherapy. In ADHD, treatment may require stimulant or newer nonstimulant medications. When both disorders are present, the mood component is treated first. Studies are looking into the effectiveness of other forms of therapy like psychotherapy for these conditions.

"The most important thing is for parents to get their child a thorough diagnostic evaluation," Penberthy tells WebMD. "That means the doctor doesn't just talk to the person who brings the child in, but gets info from multiple sources, including teachers, Little League coaches, peers, and daycare providers."

With either disorder, the earlier you catch it, the better. Proper diagnosis and treatment not only reduces the impairment in functioning due to symptoms, but it hopefully prevents the long-term effects that may occur if the disorder is untreated.

"Research shows that having ADHD symptoms in childhood can have negative effects in adolescence and adulthood, such as substance abuse, low academic achievement, interpersonal conflicts, low self-esteem, and high physical injury rates," says Penberthy.


What Is Bipolar Disorder? Symptoms, Manic Episodes, Testing See Slideshow

Untreated bipolar disorder can result in a phenomenon known as "kindling," where each episode has the effect of setting the stage for future episodes, which may worsen over time. In the case of bipolar disorder and ADHD together, there is an even greater need for careful and accurate diagnosis, since the stimulant medications that can successfully treat ADHD may actually worsen manic symptoms of bipolar disorder.

Parents also play a big role and need to be persistent in finding knowledgeable doctors and challenging them if they think their child is misdiagnosed. Even under ideal circumstances, finding the right combination of medications, especially with bipolar disorder, requires some trial and error.

Joyce (who asked that her last name not be used) went through years of misdiagnoses and incorrect treatments with her son, Shane, starting when he was 7 years old. Shane is bipolar and experienced several episodes involving mania, depression, and violence before getting his illness under control.

"He's almost 12 now, and it's taken us until this year to get the correct combination and dosage of medication," she says. "He'll never be 'normal' and will always need medication, but to anyone who doesn't know him, they now see a typical boy full of life, charm, and a kind heart."

Published Jan. 10, 2005.

SOURCES: J. Kim Penberthy, PhD, assistant professor, department of psychiatric medicine, University of Virginia. Stephanie Hamarman, MD, chief of psychiatry, Stanley Lamm Institute of Long Island College Hospital, Brooklyn, N.Y. Differentiating ADHD From Bipolar disorder in Children, George T. Lynn, MA, MPA, LMHC. National Institute of Mental health.

©1996-2005 WebMD Inc. All rights reserved.

Health Solutions From Our Sponsors