Billy. Austin 8/27/2013. ADHD & Bipolar Disorder: Differentiating the Behavioral Presentation in Children

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1 ADHD & Bipolar Disorder: Differentiating the Behavioral Presentation in Children Judy Goodwin, MSN, CNS Meadows Psychiatric Associates Billy Austin 1

2 Introduction Distinguishing between ADHD and Bipolar Disorder is a difficult challenge facing child and adolescent clinicians today. Bipolar disorder was thought to never begin until late adolescence, thus this clinical issue was never considered. Evidence exists that Bipolar Disorder can present at a very young age. Distractibility, hyperactivity and impulsivity, the three hallmark symptoms of ADHD, are no longer considered absolute indications that ADHD is present. It has now been well-established that ADHD and Bipolar Disorder can occur simultaneously 4 Which Features are Common to Both Conditions? Distractibility: Other Cognitive Impairment: Hyperactivity: Abnormally excessive talking Impulsivity 5 FEATURES UNIQUE TO EACH CONDITION Bipolar Disorder (Mania) 1. More talkative than usual, or pressure to keep talking 2. Distractibility 3. Increase in goal directed activity or psychomotor agitation ADHD 1. Often talks excessively 2. Is often easily distracted by extraneous stimuli 3. Is often on the go or often acts as if driven by a motor Differentiation: Elated mood, Grandiosity, Decreased need for sleep, Hypersexuality, and Irritable mood. Hart (2005) 2

3 ADHD The hallmark inconsistency of ADHD can present a confusing picture, as there are varying manifestations and degrees of symptomatology from person to person, and even in the same person across different situations and settings. Someone with ADHD may appear calm and organized in a relatively structured one-to-one meeting, yet ADHD is still a possibility if symptoms that interfere with smooth functioning are reported in other areas of life. FAST MINDS FAST MINDS is an acronym for the traits seen in individuals with ADHD: Forgetful Achieving below potential Stuck in a rut Time challenged Motivationally Challenged Impulsive Novelty Seeking Distractible Scattered 8 Executive Dysfunction in ADHD organizing, prioritizing, and activating for tasks Focusing, sustaining, and shifting attention to tasks Regulating alertness, sustaining effort, and processing speed Managing frustration and modulating emotion Utilizing working memory and accessing recall Monitoring and self-regulating action 3

4 ADHD Clinical Presentation Short attention spans and high levels of activity are a normal part of childhood. For children with ADHD, these behaviors are excessive, inappropriate for their age, and interfere with daily functioning at home, school, and with peers. Some children with ADHD only have problems with attention; other children only have issues with hyperactivity and impulsivity; most children with ADHD have problems with all three. As they grow into adolescence and young adulthood, children with ADHD may become less hyperactive yet continue to have significant problems with distraction, disorganization, and poor impulse control. ADHD CLINICAL PRESENTATION The core symptoms of ADHD lead to other symptoms including: distraction, being terribly forgetful, careless, loosing things, not following or carrying out instructions, making mistakes, constantly changing tasks, not organizing themselves and being unable to stick at time consuming or tedious tasks. 4

5 Gender Differences and ADHD The stereotype of someone with ADHD is a hyperactive little boy. The reality? ADHD also affects girls and even adult women. Girls with ADHD tend to be more inattentive than hyperactive. Parents and teachers often overlook ADHD in girls because their symptoms differ from the stereotype. According to researchers, girls with untreated ADHD are at risk for low self-esteem, underachievement, depression, and anxiety. Without treatment girls are also more likely to engage in risky behaviors like smoking and unprotected sex while in middle or high school. Girls with ADHD often continue struggling into adulthood if they don t receive treatment. Co-occurring Disorders Oppositional defiant disorder Anxiety or mood disorders Learning disabilities Conduct disorder Tic disorders ½ of ADHD patients have > 2 diagnoses Overlap of Symptoms and Diagnoses ADHD Anxiety LD ODD Trigger for anger Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep 5

6 Bipolar Disorder Highly genetic Conservative estimate of risk is 1% for general population With one parent bipolar each child s risk is 15-30% Both parents bipolar 50-75% Sibling and fraternal twins risk is 15-25% Identical twins risk is 70% Child/Adolescent Bipolar Disorder It is now believed that symptoms of bipolar disorder can emerge in early childhood. While older adolescents often have a clinical presentation that is somewhat similar to that seen with adults. The clinical presentation of early-onset bipolar disorder in children can look quite different than that seen in older individuals. Child/Adolescent Bipolar Disorder: Clinical Presentation Mothers often report that children, later diagnosed with early-onset bipolar disorder, were extremely difficult to soothe and slept erratically. They seemed extraordinarily clingy and, from a very young age, often displayed uncontrollable, seizurelike tantrums or rages out of proportion to any event. These severe tantrums often appear to be without provocation. Depression and dysphoria are an almost constant part of pediatric bipolar disorder. As noted earlier, hyperactivity is often the first manifestation of early-onset bipolar disorder. 6

7 Child/Adolescent Bipolar Disorder: Clinical Presentation When children are initially seen because of bipolar symptoms, approximately 90% of early-onset, and 30 % of adolescents with bipolar disorder meet criteria for a diagnosis of ADHD. Comorbid conduct disorder is also quite common. Children, more often show rapid cycling and mixed states rather than clear manic or clear depressive episodes, and an ongoing and continuous mood disturbance that is a mix of mania (or hypomania) and depression. The rapid and severe cycling between moods produces chronic irritability and few clear periods of wellness between episodes. Child/Adolescent Bipolar Disorder: Clinical Presentation With children, initial symptoms of the disorder can be depressive in nature With these being confused with and treated as MDD. In other cases, ADHD like symptoms appear first with these symptoms being followed later by a full manic episode. Unlike adults - children in a manic state are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. Child/Adolescent Bipolar Disorder: Clinical Presentation As with adults, Bipolar disorder in children is viewed a serious mental disorder Characterized by recurrent episodes of depression, mania, and/or mixed symptom states. Some evidence suggests that child bipolar disorder may be a different and possibly more severe form of the illness than older adolescent and adult-onset bipolar disorder. 7

8 Reliable and Consistent Diagnostic Tests for ADHD and Bipolar Disorder None 22 ADHD ASSESSMENT Referrals are typically prompted by academic and/or behavioral problems Diagnosis requires meeting DSM-V criteria Clinical diagnosis requires input from parents, teachers, practitioners Specific physical tests not available Medical and neurological status evaluated ADHD- Screening Tools Academic Performance Rating Scale (APRS) ADHD Rating Scale-IV Brown ADD Rating Scales for Children, Adolescents, and Adults Child Behavior Checklist (CBCL) Conners Parent Rating Scale- Revised (CPRS-R) Conners Teacher Rating Scale- Revised (CTRS-R) Conners Wells Adolescent Self-Report Scale Home Situations Questionnaire- Revised (HSQ-R) School Situations Questionnaire-Revised (SSQ-R) Inattention/Overactivity with Aggression (IOWA) Vanderbilt ADHD Diagnostic Parent and Teacher Scales 8

9 BIPOLAR - ASSESSMENT American Academy of Child and Adolescent Psychiatry Recommendations: The DSM-IV-TR Criteria, Including the Duration Criteria, Should Be Followed When Making a Diagnosis of Mania or Hypomania in Children and Adolescents The diagnostic validity of bipolar disorder in young children has yet to be established. Caution must be taken before applying this diagnosis in preschool children. History, history, history!!! Rule out disruptive behavior disorders, posttraumatic stress disorder, and pervasive developmental disorders (they all have manic-like symptoms of irritability and emotional reactivity) BIPOLAR - ASSESSMENT Preschool children who present with mood and behavioral concerns must be carefully assessed for other contributing factors, including developmental disorders, psychosocial stressors, parent-child relationship conflicts, and temperamental difficulties. Manic grandiosity and irritability present as marked changes in the individual s mental and emotional state, rather than reactions to situations, temperamental traits, negotiation strategies, or anger outbursts. The pattern of illness, duration of symptoms, and association with psychomotor, sleep, and cognitive changes are important diagnostic clues. Bipolar Disorder- Screening Tools At present, the best validated and most discriminating instruments are: The Parent General Behavioral Inventory and its 10 item mania form The Parent Mood Disorder Questionnaire, and The Child Mania Rating Scale and its 10 item form. 9

10 In summary Always consider the differential for a diagnosis, especially if there is anything atypical in the presentation Have a panel of colleagues in other specialties to consult with A thorough work-up sometimes includes medical examination/ laboratories/ radiographic/ psychoeducational testing Citations 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC, American Psychiatric Association, Practice Parameter for the Assessment and Treatment of Children with Bipolar Disorder, Journal of American Academy of Child Adolescent Psychiatry, 2007;46(1): Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/ Hyperactive Disorder, Journal of American Academy of Child Adolescent Psychiatry, 2007;46(7): Executive: Describing Six Aspects of a Complex Syndrome, Attention, 2008, February: The State of the Evidence on Pediatric Bipolar Disorder, Psychiatric Times; 26(12):

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