Evidence-Based Reviews

ADHD or bipolar disorder? Age-specific manic symptoms are key

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Chronic irritability, grandiosity point to bipolar diagnosis.


 

References

Knowing what to look for can help you differentiate between pediatric bipolar disorder and attention-deficit/hyperactivity disorder (ADHD):

  • Bipolar disorder is a problem with mood. Children with bipolar mania are elated and/or irritable and experience mood states that appear uncontrollable.
  • ADHD is a problem with cognitive functioning, including attention, distractibility, and energy level.

Mood and cognitive symptoms may overlap,1,2 but recognizing manic features is the key to distinguishing between these disorders—even when they co-occur.

We offer tips from our experience and a recent clinical trial to help you sort out the core symptoms that point to bipolar mania.

BIPOLAR CORE SYMPTOMS

Pediatric bipolar disorder is relatively rare, but children with it can experience substantial impairment and developmental delay. Intervening early with effective treatment3 can improve their quality of life, function, and prognosis.

Diagnostic criteria for type I bipolar disorder require at least one manic episode and are the same for all ages. Many clinicians and researchers have advocated adapting DSM-IV criteria for children, but we believe separate adult and pediatric criteria would confuse discussions about the same phenomena. We do agree that symptoms should be evaluated in a developmentally appropriate context, as mania can present differently across the ages (Table 1).

Mania in children and young adolescents tends to present with rapid cycling and a primarily irritable mood.4 Older adolescents and adults may present with more-distinct mood changes, with a primarily euphoric mood. Euphoric mania is less common in adults than previously thought. Forty percent to 60% of adults with bipolar disorder experience a chronic course, rather than more-discrete mood episodes.

A manic episode is an abnormally and persistently elevated (euphoria) or irritable mood that lasts at least 1 week. To satisfy DSM-IV-TR diagnostic criteria for a manic episode:

  • patients with euphoria require three additional symptoms
  • those who are irritable (and not euphoric) require another four symptoms.5

These symptoms must significantly impair several areas of functioning and not be caused by other mental or physical illness, including substance use or abuse. When depressive symptoms occur in the same week as mania, the mixed mania modifier is used.

Table 1

Diagnostic features of bipolar mania in adolescents vs adults

FeaturePrepubertal and early adolescentOlder adolescent and adult
Initial episodeMixed presentations predominateMania is more balanced between mixed and euphoric
Episode typeMore consistently illPersistent/distinct episodes
Primary moodIrritableEuphoric
DurationChronic, continuous courseWeeks
Inter-episode functioningLess distinct episodesMay return to baseline or deteriorate over time
Reality testingDelusions (grandiosity) is common; hallucinationsMore variable

Disruptive and aggressive behavior are common and are what usually prompts parents to bring children to psychiatrists. These behaviors are not diagnostic of mania, however, and aggression has many other causes.

The threshold between a variant of normal and pathologic disruptive behavior can be difficult to establish and varies from culture to culture. Some families, for example, would allow a child to tell the parents what to do, whereas other families consider this a serious boundary violation.

Prolonged rages have been used as a proxy for mood swings. Although we agree that rages lasting >15 minutes and out-of-proportion to the circumstances may signal bipolar disorder, they are not diagnostic.

Other symptoms. Psychotic symptoms (hallucinations, delusions, disorganization) can occur in youths with bipolar disorder. Evaluation often reveals impaired social and cognitive development. Keep in mind that a child’s developmental level can affect symptom expression.

ADHD CORE SYMPTOMS

Children with ADHD often present with hyperactive, uncontrollable behaviors and academic failure. To meet DSM-IV-TR diagnostic criteria, they must show symptoms before age 7. Primary symptoms may be inattention, hyperactivity and impulsivity, or both.

ADHD is a disorder of attention and the cognitive skills related to attention, rather than a mood disorder. Children with ADHD show substantially impaired function in at least two settings (such as at home and in school), and—unlike bipolar disorder—their symptoms are persistent rather than episodic.

DIFFERENTIATING BY SYMPTOMS

When differentiating between ADHD and bipolar disorder in children, remain focused on both diagnoses’ core symptoms.

Euphoria, or elation, is a key distinguishing factor in bipolar disorder.6 Although all children are at times giddy or silly in appropriate environments—such as during slumber parties—consider a threshold of appropriateness when making a bipolar diagnosis. Families perceive the giddiness, inappropriate laughter, and elevated mood of children with mania as disturbing and inappropriate, not funny or endearing. They are often annoyed and concerned.

Children with primary ADHD do not show inappropriately elevated mood. In fact, their failures often make these children dysphoric.

Irritability is common in children with psychiatric illnesses. Manic youngsters can be very irritable most of the time. Families describe “walking on eggshells” because of these children’s touchiness. Unpredictable triggers set off explosive, prolonged tantrums that may be associated with aggression, and their mood swings are almost constant.

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