Is It ADHD or Bipolar Disorder?

Bipolar disorder is a mood disorder characterized by periods of extreme highs and lows that usually appears in the teen or young adult years. Some children develop it earlier, though it’s often difficult to diagnose in children. That’s because pediatric bipolar disorder looks significantly different from the adult version. And, to make it more confusing, it often looks a lot like ADHD.

Bipolar disorder in adults is defined by intermittent episodes of mania — elevated mood, rapid speech, high energy, grandiosity and overconfidence — that can last from a week to several months. But mania in children looks different from the symptoms we associate with adult mania. In children, instead of euphoria, mania usually takes the form of increased irritability and aggression.

But relying solely on irritable behavior is problematic. What experts call “emotional dysregulation,” which includes tantrums, outbursts and aggression, occurs in many conditions — among them ADHD. It’s only when this occurs episodically, along with other manic symptoms, that it can be a manic/bipolar episode.

Emotional dysregulation, explains Gabrielle Carlson, MD, was one of the symptoms of ADHD (along with inattention, impulsivity and hyperactivity) until 1980 when the DSM-3 committee decided it was not part of the core condition. But it’s still listed as an associated behavior. The current DSM-5 describes it as “low frustration tolerance, irritability, or mood lability.” Its importance in kids with ADHD has recently gained renewed recognition.

Dr. Carlson is director emerita of the Division of Child and Adolescent Psychiatry and professor of psychiatry and pediatrics at Stony Brook University School of Medicine. She is an expert in bipolar disorder in children and the more recently defined condition called disruptive mood dysregulation disorder.

Difficulty managing their emotions and meeting expectations for behavior are common problems for children with ADHD. Indeed, more than half of children with the combined form of ADHD (inattention as well as impulsivity and hyperactivity) develop a behavior disorder like oppositional defiant disorder (ODD), which is characterized by temperamental, disruptive and disobedient behavior. Indeed, the irritability of ADHD and ODD is indistinguishable from the irritability of mania except that the latter is episodic rather than continuous.

Emotional dysregulation isn’t the only symptom that is associated with both bipolar mania and ADHD. In fact, there are many behaviors could be interpreted as signs of either mania or ADHD, Dr. Carlson notes. For instance:

• One criteria of mania is heightened activity, which can look like the hyperactivity associated with ADHD
• The irritability of mania looks like the low frustration tolerance that comes with ADHD
• The poor judgment of mania looks like impulsivity of ADHD
• Both include distractibility
• Both include difficulty sleeping

The key distinction is that mania comes and goes episodically, while ADHD is a chronic condition. The low frustration tolerance of ADHD does not go away, while a child with bipolar disorder could be severely irritable for six months and then not have another episode for years.

Compounding the potential for confusion, Dr. Carlson adds, is that the diagnostic tools clinicians use to evaluate a child’s behavior — called structured interviews—may ask parents to rate symptoms but not ask whether they are episodic and unexplained by other stressors or environmental changes. That information, of course, is key to ruling out one or the other diagnosis.

In some research studies, the difficulty distinguishing symptoms of mania from symptoms of ADHD results in these symptoms being counted toward both disorders, once as a symptom of bipolar disorder and once as a symptom of ADHD. And that, in turn, may lead to kids who have either ADHD or bipolar being diagnosed, in error, with both.

That said, it is possible for kids to have both conditions. And confusion about whether a child has ADHD or bipolar, or both, can lead to difficulty in treatment decisions. If there is diagnostic uncertainty, which should be treated first? Dr. Carlson advises treating the ADHD first. Since ADHD is much more common than bipolar in children, ADHD is the more likely correct diagnosis.

But, more importantly, stimulant medications, the first-line treatment for ADHD, produce results quickly. Their effectiveness (or lack of effectiveness) should be clear within days or weeks at most. With some regularity, Dr. Carlson says, she sees kids who have been diagnosed with bipolar whose parents are surprised and thrilled to see their symptoms go away with stimulant medication, because these kids actually have ADHD rather than bipolar.

And if a child turns out to have bipolar, stimulant medication has not been shown to impact their illness detrimentally like some other medications, including antidepressants, which can trigger mania.

If a child is prone to severe irritability with explosive outbursts, but the behavior is not episodic, it’s possible that he may fit the criteria for the new diagnosis, disruptive mood dysregulation disorder, or DMDD. DMDD was added to the list of diagnoses in DSM-5 when it was published in 2013, to identify children with severe mood dysregulation who would previously have been diagnosed with pediatric bipolar disorder. The problem was that children who fit this description often did not go on to develop adult bipolar disorder.

Children with DMDD are prone to outbursts that are out of proportion to the trigger, and are irritable in between outbursts, but this behavior differs from bipolar mania in that it does not alternate with periods of depression or normal mood.

If a child fits the criteria for DMDD, he may still have ADHD, in fact Dr. Carlson estimates that about 75 to 80 percent of children in clinical samples do have ADHD, and treating the ADHD that underpins the explosive behavior may be the most important opportunity to help them. However, emotion dysregulation may be a severe problem with its own burdens leading to emergency room visits and psychiatric hospitalizations. Many children do not respond either to ADHD medications or to mood stabilizing medications. Finding appropriate interventions for these children, Dr. Carlson adds, is a high priority.