Bipolar & Children: ADHD or Mania?

Last Updated: 5 Sep 2018
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In children and teens with ADHD, up to 20 percent have a co-morbid mood disorder. Referencing “cardinal symptoms” helps distinguish between ADHD and bipolar mania.

bipolar-children-adhd-mania

 

Pediatric attention deficit hyperactivity disorder affects 4–8 percent of preteens and 4 percent of those in adolescence and beyond. In children with ADHD, up to 20 percent have a co-morbid mood disorder, the most common being major depression. Bipolar disorder affects about 1 percent of adolescents overall and is less common in prepubertal children.

How are pediatric mania and ADHD alike?

Children with either diagnosis may be restless, impulsive, and inattentive. They frequently have poor peer interactions and poor or deteriorating academic performance, and may also have signs of co-morbid conduct disorder or disruptive behavioral symptoms, such as oppositionality. They may exhibit difficulties both at home and at school in following rules—but children with ADHD don’t follow the rules because they act without thinking; in contrast, children with mania know their actions are wrong but feel that the rules do not apply to them.

How does ADHD differ from mania?

ADHD has a younger age of onset—as early as preschool—and there is a chronic course of impulsive, restless, and inattentive behavior. Family history is positive for ADHD in 10–35 percent of cases, and up to 26 percent of kids with ADHD have a family member with a mood disorder. Mood is variable, and people with ADHD do not experience delusions or hallucinations. Speech may be rapid but is not tangential (that is, they don’t wander off-topic and never come back to the original thought). They do not have a decreased need for sleep, though they may have trouble falling asleep at bedtime; they may have some loss of appetite due to the effects of ADHD treatment, such as stimulants; and they have a long-term pattern of high-level purposeless energy or hyperactivity. Seventy-five to 90 percent of those with ADHD show rapid improvement when treated with stimulants. Mood stabilizers are not effective for ADHD.

Bipolar disorder is usually the acute onset of impulsivity, motor restlessness, and inattention. Only 0.5 percent of youth are diagnosed with bipolar disorder before puberty. In 22 percent of prepubertal children and 18 percent of adolescents with mania, we find a recent deterioration in schoolwork and social activities and a new onset of disruptive behavior. There is a positive family history of bipolar disorder in up to 10 percent of first-degree relatives (spouse, parent, sibling, child). Youth with bipolar disorder may have a euphoric or irritable mood, delusions of grandeur, paranoia, and auditory or visual hallucinations. They frequently have pressured and tangential speech (wandering off-topic on different tangents) and are internally distracted with racing thoughts. They have a decreased need for sleep, a marked increase or decrease in appetite with weight change, and often new-onset boundless energy. Treatment with stimulants may increase or decrease their symptoms. Mood stabilizers can improve symptoms of mania in three to six weeks, depending on the medication.

What do I do for my child who has both?

For the child with ADHD, the time of risk for the development of bipolar disorder increases after puberty. Parents should be paying attention and consulting their clinician if their child with previously stable ADHD develops new symptoms. Multiple studies have shown that the mood must be stabilized first; then ADHD medications can be judiciously added back in to the treatment regimen. For parents of teens with bipolar disorder, they may wish to ask about ADHD if their child’s mood is stable on medication but he or she continues to struggle academically with poor focus and attention.

Due to the high level of overlap and co-morbidity, several academic bipolar experts have examined the key distinguishing symptoms between childhood ADHD and mania. The cardinal symptoms of bipolar disorder include elation or euphoria, grandiosity, racing thoughts, decreased need for sleep, and hypersexuality. Referencing these cardinal symptoms helps to distinguish between mania and ADHD.

 

Code: bphopekids

Printed as “ADHD or mania?”, Winter 2017

About the author
Adelaide Sherwood Robb, MD, a board-certified child and adolescent psychiatrist, is division chief of psychology and behavioral health at Children’s National Health System, in Washington, DC; she also is a professor of psychiatry and pediatrics at The George Washington University.
2 Comments
  1. Please read

  2. Dra. A bipolar can use Ritalin?

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