Stimulants are most effective for childhood attention-deficit/hyperactivity disorder (ADHD),1 but they may induce mania or trigger a treatment-resistant course in children with comorbid bipolar disorder. To help you safely manage these complicated symptoms, this article offers a treatment algorithm and tips to:
- differentiate bipolar and ADHD symptoms
- identify patients at risk for stimulantinduced mania
- choose medications by a hierarchythat may reduce the risk of mood destabilization.
Bipolar disorder and ADHD: High comorbidity, greater impairment
Bipolar mood symptoms emerge before age 20 in about 25% of persons with bipolar disorder (BP).3 Early-onset BP may be more severe than the adult-onset form, with more-affected family members and greater comorbidity with other disorders, especially ADHD.4
In one study, 91% of children with BP also met criteria for ADHD, and 19% of patients with ADHD also received a diagnosis of BP.5 Among 31 children ages 2 to 5 with BP, 80% met criteria for concurrent ADHD.6
Of 40 children age <5 presenting consecutively to a mental health clinic, 11 (28%) met criteria for mania, which was usually associated with euphoria.7 These 11 children also met criteria for ADHD.
A comparison study8 of children (mean age 12) found greater impairment, suicidality, irritability, and sadness in 43 with ADHD plus bipolar depression than in:
- 109 with ADHD plus major depressive disorder
- 128 without depression or mania.
Family prevalence of bipolar disorder and major depression was highest in the bipolar-ADHD group, which also had the highest rates of comorbid conduct disorder, oppositional defiant disorder, alcohol abuse, and agoraphobia. Average age of bipolar diagnosis was 6.3 years.
Adhd and/or bipolar disorder?
Some 70% to 90% of bipolar children and at least 30% to 40% of bipolar adolescents also have ADHD.2 This high comorbidity (Box 1)3-8 might mean that:
- one disorder predisposes to the other
- one is a precursor of the other
- they share common vulnerabilities or causes
- their symptoms overlap so much that patients with one disorder appear to meet criteria for the other.
Some experts contend that bipolar disorder and ADHD usually can be differentiated. Bipolar children score higher than those with ADHD on measures of anxiety/depression, aggression, and attention problems on the Child Behavior Checklist.9 Others believe ADHD symptoms that occur with bipolar disorder are a dimension of bipolar illness rather than a separate disorder.10
For every DSM-IV-TR diagnostic criterion for ADHD, a corresponding diagnostic criterion or common feature of bipolar disorder can be identified (Table 1). Mania and hypomania are obviously associated with hyperactivity and impulsivity, and tangential thinking and distractibility interfere with attention in many patients with bipolar disorder.
Though most ADHD symptoms can occur in bipolar patients, some features of bipolar illness are not characteristic of ADHD (Table 2). Children with ADHD can become hyper-focused on video games and television, for example, but they usually do not become engrossed in long, complicated books or preoccupied with other people, as can occur in bipolar disorder.
Table 1
How ADHD, bipolar symptoms overlap in three domains
| ADHD | Bipolar disorder |
|---|---|
| Inattention | |
| Fails to pay attention | Racing and tangential thoughts |
| Difficulty sustaining attention | Attention driven by racing thoughts, affective themes, and psychosis |
| Does not follow through | Direction of activity shifts with shifting mood |
| Difficulty organizing tasks | Disorganization, psychosis, excessive energy |
| Easily distracted | Distractibility |
| Hyperactivity | |
| Fidgets or squirms | Increased energy and activity |
| Runs about or climbs excessively | Hyperactivity, thrill-seeking |
| Difficulty engaging quietly in leisure activities | Increased energy, boredom |
| Often on the go | Increased energy, hyperactivity |
| Talks excessively | Rapid, pressured speech |
| Impulsivity | |
| Blurts out answers | Rapid, pressured, impulsive speech |
| Difficulty awaiting turn | Hyperactivity, increased energy, impatience, grandiosity |
| Interrupts or intrudes on others | Grandiosity, impatience, pressured speech, increased mental content |
Table 2
Bipolar features not seen in ADHD
|
A treatment hierarchy
Whether a bipolar patient’s attention problems are features of the primary condition or caused by comorbid ADHD may be unclear, but the treatment implications are important. All antidepressants can induce mania/hypomania and increase the risk of mixed states and mood cycling. Because stimulants have antidepressant properties and because some antidepressants are used to treat ADHD, a systematic approach is necessary when treating inattention in juvenile bipolar disorder.
A treatment hierarchy developed by the American Academy of Child and Adolescent Psychiatry Workgroup on Bipolar Disorder recommends beginning psychosocial approaches, such as training parents in behavior management techniques, and:
- treating bipolar disorder first in children who clearly have both ADHD and bipolar disorder
- adding ADHD treatment if ADHD symptoms persist and impair functioning.2
Who’s at risk for mood destabilization?
No data address differences between bipolar patients whose mood disorders deteriorate with stimulant use and those who remain stable. However, risk factors for mood destabilization that have been reported with antidepressants likely also apply to stimulants (Table 3) because stimulants’ adverse effects in bipolar disorder are probably related to their antidepressant properties.