Psychotherapy expert: ADHD, Bipolar disorder

Vol XX: 'Does our child have ADHD, Bipolar Disorder, or both?'

By DR. MIKE GROPPER
dr mike 88 (photo credit: )
dr mike 88
(photo credit: )
Dr. Mike is a licensed clinical social worker (USA and Israel) in private practice in Ra'anana. He recently wrote a column called "Psych-Talk with Dr. Mike" in which the feedback from readers was excellent. He has decided to shift gears and invite readers to submit their questions concerning a wide range of topics: child development, adult problems, addictions, ADHD, adjustment problems, crises and transitions, trauma, phobia, mental disorders such as anxiety, depression, and bi-polar. He also welcomes questions concerning your marital or couple relationship, family issues, parenting, problems at work, self-confidence, shyness and much more. "I take pleasure having the opportunity to answer your questions in what I hope will be an informative and exciting weekly column in the Jerusalem Post-online edition. Look forward to hearing from you soon." Dr. Mike Gropper, DSW (09) 774-1913 Send your questions for Dr. Mike. * * * Psych-Talk with Dr. Mike: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Click here for Volumes I-IV Click here for Volumes V-IX Click here for Volumes X-XIII Click here for Volumes XIV-XV Click here for Volumes XVI-XIX * * * This column is intended solely to educate and is not a substitute for personal diagnosis or treatment. If you have a difficult problem, please seek advice from your own doctor or mental-health professional. * * * Vol XX Q: Our 14 year old son was diagnosed with ADHD when he was in second grade. He currently takes time-released Ritalin, which in the beginning seemed to work. He has, nevertheless, had a history of moodiness with his moods going from very up and filled with endless energy and then even several times in the same day, he can become rapidly depressed and withdrawn. When he is up, he commits pranks with other kids in the neighborhood, some of which have become so serious recently, that he is about to get himself thrown out of school. He just loses control. At night, he has difficulty sleeping. There is a history of bipolar illness in my husband's family. We suspect that maybe there is more going on here than simply ADHD. A: A source of diagnostic confusion to many child psychotherapists is the overlap with many symptoms in childhood bipolar disorder and attention-deficit disorder with hyperactivity. ADHD is among the most common mental disorders among children. An estimated 3 to 5 per cent of children are affected - approximately 2 million children in the US. In a classroom of 25 to 30 children, it is likely that at least one will have ADHD. Attention deficit disorder is characterized by a child meeting six or more of the following eighteen symptoms (at least six in the first category, or at least six in the second category). A child with ADHD can either have inattentive (daydreamer) and/or hyperactive-impulsive types of the disorder. 1. Inattention Symptoms
  • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
  • Often has difficulty organizing tasks and activities
  • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
  • Is often easily distracted by extraneous stimuli
  • Is often forgetful in daily activities 2. Hyperactivity and Impulsivity Symptoms
  • Often fidgets with hands or feet or squirms in seat
  • Often leaves seat in classroom or in other situations in which remaining seated is expected
  • Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
  • Often has difficulty playing or engaging in leisure activities quietly Is often "on the go" or often acts as if "driven by a motor"
  • Often talks excessively Often blurts out answers before questions have been completed
  • Often has difficulty awaiting turn
  • Often interrupts or intrudes on others (e.g., butts into conversations or games) These symptoms must be present for at least 6 months in two or more settings, e.g., school and at home; play and at school; etc. The symptoms usually go back to the first grade. If the symptoms have not been present for at least 6 months, or the child meets the criteria only in one setting (e.g., school only), then ADHD should not be diagnosed. Bipolar disorder affects an estimated 1-2 percent of adults worldwide. The more we learn about this disorder, the more prevalent it appears to be among children.
  • It is suspected that a significant number of children diagnosed in the United States with attention-deficit disorder with hyperactivity (ADHD) have early-onset bipolar disorder instead of, or along with, ADHD (Estimates are between 11-20%).
  • Depression in children and teens is usually chronic and relapsing. According to several studies, a significant proportion of the 3.4 million children and adolescents with depression in the United States may actually be experiencing the early onset of bipolar disorder, but have not yet experienced the manic phase of the illness. Behaviors in children diagnosed with bipolar disorder may include:
  • an expansive or irritable mood
  • extreme sadness or lack of interest in play
  • rapidly changing moods from highs to lows lasting a few hours to a few days
  • The highs may be either mania or hypomania. Mania expresses itself in explosive and almost psychotic type destructive rages which resemble a severe temper tantrum. Most of the children with the disorder that I have seen, however, have hypomania, an expansive mood when they are high that consists of endless energy, involvement in multiple projects and activities with impaired judgment, impulsivity, racing thoughts, pressure to keep talking, and grandiosity and/or euphoria sometimes leading to oppositional behavior and committing pranks and doing risky things such as jumping off of roofs or riding on the back of a bus where this child may get hurt or hurt others. When these children are high, they have trouble also falling asleep and their minds are continuously racing. There is another category of bipolar disorder which is less known about but getting more recognition by psychiatrists specializing in the disorder. These children have moods that go up and down, often many times in the same day or week, but instead of from highs to lows, they swing from a normal state to depressed state or from a depressed state to an even more depressed state. These kids are often quite self-destructive when depressed and may use drugs and/or alcohol to self-medicate their depression. Bipolar depression can lead to suicidal gestures or self-mutilating behavior such as cutting their skin with a razor blade, knife, or finger nails.
  • separation anxiety
  • defiance of authority
  • hyperactivity, agitation, and distractibility
  • sleeping little when overly stimulated and high or, alternatively, sleeping too much when depressed
  • strong and frequent cravings, often for carbohydrates and sweets
  • inappropriate or precocious sexual behavior at a very early age. What Are the Differences between ADHD and Bipolar? While ADHD is characterized by inattention and most often some hyperactivity, bipolar disorder is characterized by mood swings as described above. While children with ADHD may sometimes feel sad for no reason, children with bipolar disorder may feel sad for weeks on end for no discernible cause. Both the manic feelings and the depressive feelings in the child create significant problems for him or her throughout virtually every aspect of their lives - school, play, friends, home, etc. A bipolar child's mood is pervasive and seems impossible to shake, while a child with ADHD's mood may come and go, but generally they are neither particularly depressed nor manic. A child with ADHD doesn't generally lose touch with reality during a temper tantrum, which tend to be short in duration and do not include the destruction of property. A bipolar child may lose touch with reality during a temper tantrum, destroy property, and the tantrum itself may last for hours. Also, bipolar children are likely to have depression as a source of their inattentiveness, while ADHD kids; their inattentiveness is caused by an inability to focus, but not by depression. ADHD kids are very sensitive to the feeling of others, and they wear their hearts on their sleeves. They can have a nighttime hyperarousal that is usually a medication side effect.  The BD kid comes alive at night when his serotonin level is at a 24-hour low and may become unbearably nasty, have fits of rage, or tyrannize everyone in the family.  Constant irritability and inability to sleep are two of the main criteria for diagnosing BD.    Another way to differentiate between these two diagnoses is through treatment. When a bipolar depressed child is given an antidepressant, their mood generally improves after a few weeks and their attention and energy returns. If the bipolar child is in a manic episode, a type of antipsychotic medication may be prescribed which will eventually help even out and lower the child's energy levels. In contrast, a child with ADHD is given a stimulant, a medication that works usually more quickly than an antipsychotic or antidepressant drug. Within a few days, the child is usually able to better focus and lower their energy levels as though a switch had been turned off. Getting the Right Diagnosis It sounds to me like your child may in fact have both ADHD and bipolar disorder, considering the mood swings and his destructiveness when he is committing pranks. Also, his inability to get to sleep could also be indicative of mind-racing. Nevertheless, many other things needs to be considered and ruled out before one would conclude that he does in fact have bipolar disorder such as other emotional and family problems that could explain his behavior, how long these behaviors have been around, medical illnesses, and also what is going on in his emotional life with friends and peers. It is important that you take your son to a child psychotherapist who also works with adolescents and a competent child psychiatrist, both of whom have expertise in assessing both ADHD and bipolar disorder in kids. Get recommendations and then ask these professional what their experience is in this area of diagnosis. Two opinions are also recommended to be certain that there is inter-clinician reliability. Lastly, if your son has both bipolar disorder and ADHD, the child psychiatrist will have to prescribe a mood stabilizer and also treat the ADHD with a psycho stimulant drug. Good luck. * * * Send your comments >> Cafe Oleh experts have been chosen for their knowledge and reputation. Cafe Oleh does not take responsibility for any advice they offer.
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