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Attention-Deficit Hyperactivity -- or Bipolar?
(updated 5/2005)

Last week I saw an 18 year old, whose mother is convinced he has ADHD.  She's probably right.  However, he may also have a Bipolar condition.  The Bipolar Disorder, if he has it, might actually account for some or even all of his attention/distractibility problems.  I've seen at least one adult on a stimulant have better attention/focus abilities when she was off the stimulant and on a mood stabilizer.  Should this 18-year-old be given a stimulant?

Mood stabilizers do not seem to make ADD worse, but a stimulant could make bipolar disorder worse.  This is not firmly established nor agreed upon.  However, for the moment, caution seems warranted.  For example, here is Dr. Faedda, quoted by Dr. Papolos -- two of the leading researchers on bipolar disorder in children:  "It should be emphasized that antidepressants can cause a trial of a mood stabilizer to look as though it has failed because the antidepressants can be very destabilizing for a child or adult with bipolar disorder. Stimulants can do the same thing."  (This is controversial; there are no sufficient data to say yes or no on this debate at this point). 

Therefore ruling out the presence of bipolar disorder before giving a stimulant to a child is clearly warranted.  But how?  The two conditions, in children, have substantial overlap of symptoms.  Moreover, they have substantial co-morbidity as well:  in one study in prepubertal kids, of those who clearly had bipolar disorder, 90% also had ADHD.  So clearly, at least in very young children, one will have to be looking for bipolar disorder underneath ADHD symptoms.  What to look for?  

Information that might help with this decision is presented in the graph below.  This is the recent research of Dr. Barbara Geller and colleagues (see summaries of more similar work, including Dr. Geller's group, in the Reference Room in the Learning Center on BPKids.org).   

For your amusement, and to remember all this better, try this quiz.  In the bar graph below, which shows results from Dr. Geller's work, ask yourself:   which are the four symptoms which -- as you can see from the left set of bars -- distinguish pre-pubertal or early adolescent bipolar (PEA-BP) from ADHD?  A list of candidate symptoms appears just below the graph (remember these matching tests from your school days?).  Focus on picking the four which best distinguish the two conditions.  

 

 

When you've made your guesses -- a process which will help you remember, when you get the actual results -- click here to see the matched graph, then return. 

Here are two more symptoms of interest not clear from the bar graph above: 

Symptom

Bipolar

ADHD

Hypersexuality

   45% of entire BP group
     before puberty:  24%
        after puberty:  70%

8%

Suicidal thoughts with plan or intent

27%

0%

And one more finding of interest, among the 60 children with Bipolar Disorder:

Ultra-rapid cycling
   (avg. 4 cycles/day)

75%

Cycles last days or  weeks

8%

This is a very controversial area within Child Psychiatry.  There are few simple or clear guidelines to follow.  I hope this information will be useful to parents and providers as they work together to decide on a course of action.   Updates will follow as new data and opinions emerge.   For more reading on this topic, follow the links above to BPKids and their Learning Center resources, which are extensive (though many are quite technical).