Abstract
The relationship between Attention Deficit Hyperactivity Disorder (ADHD) and bipolar disorder has received a lot of attention. Several studies carried out have yielded reports suggesting possible association between ADHD and bipolar disorder, however, debates still linger on the explanation to the co-occurrence of the two especially in young children.
The complexity in co-occurrence of the two illnesses makes it hard to differentiate children suffering from ADHD from those with bipolar disorder. This study evaluated the relationship between ADHD and bipolar disorder in children.
We assessed symptoms related to ADHD and bipolar. We reviewed recent literatures and recorded findings. From the findings, there was bidirectional relationship between ADHD and bipolar. Studies yielded results that indeed showed the possibilities of co-occurrence of ADHD and bipolar in children. Most studies also revealed the comorbidity of ADHD and bipolar in children as a complex diagnostic situation.
Introduction
Recent debates focusing on controversies surrounding misdiagnosis of bipolar disorder in children experiencing emotional and behavioral problems have confronted the psychiatric profession. Additionally, the exposure of children to mood stabilizers as a medical procedure has received a lot of controversies.
Even though the Food and Drug Administration (FDA) has approved functional prescriptions for children, such uncertainties may lead to lack of treatment of bipolar disorder in children, and underdiagnosis in youths. Therefore, attempts to understand concerns surrounding the diagnosis confusion are important.
The key component element featured in the debates on the legitimacy of bipolar diagnosis in youth is supported by the high overlap of bipolar disorder with ADHD (Milberger, et al., 1995). Both ADHD and bipolar disorder exhibit behavioral symptoms associated with physical hyper activeness, disruption, and agitation.
Thus, behavioral symptoms associated with ADHD like lack of patience, attention and organization are possibly shown by the elements of mania in bipolar disorder. Besides, various mania symptoms, for instance euphoria likely occur the same time with ADHD (Geller, et al., 2002). Farther, the diagnosis of ADHD is complicated by the inclusion of elements that de-regulate emotions (Anastopoulos, Smith, & Garrett, 2011).
Predicaments surrounding the diagnosis of bipolar disorder in adolescents and children are broadly taken, especially with the comorbidity nature of bipolar disorder and ADHD. Issues related to misdiagnosis of the two mental conditions are enclosed by different arguments and dependable findings.
This report gives a background study on the relationship between bipolar disorder and ADHD and the degree of co-occurrence and future relationships of ADHD and bipolar disorder in children. Further, the report proposes clinical recommendations and supplementary areas of research to improve diagnostic treatment.
Research questions
Prospective explanations on the co-occurrence between ADHD and bipolar disorder exist. This report will scrutinize different explanations using statistics from clinical and genetic studies. The report will investigate if there is evidence to support that:
- Bipolar symptoms lead to over-diagnosis of ADHD in children with bipolar disorder
- ADHD is a prior expression of bipolar disorder diagnosis in children
- ADHD and other linked factors lead to early diagnosis of bipolar disorder in children
The details above evoke similar features between bipolar disorder and ADHD that can be investigated using facts from current literature. Therefore, we will use the details to survey prospective relationships between ADHD and bipolar disorder.
Significance of the Study
The importance of accurate diagnosis is widely assumed by either side of the argument. Bipolar underdiagnosis especially in children and youth may lead to lack of early treatment. On the other side, overdiagnosis of bipolar disorder in ADHD children would have short and long term effects caused by mood stabilizers and antidepressant medication procedures.
Farther, the assumption of non existence of ADHD in bipolar kids and vice versa may underutilize preventive measures. Therefore, it is important to examine literature on reliable differentiation techniques of these disorders, and diagnostic uncertainties resulting from both disorders.
Research Background
Before we examine the co-occurrence of the two disorders, it is important to study each mental condition. Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood disorder. Recent reports indicate that ADHD prevalence in America rates at 9.6 percent of school-age children (Leibenluft, et al., 2003).
ADHD is a neurodevelopment psychiatric disorder that causes substantial problems of attention, acting impulsively, and hyperactivity, which is inappropriate as compared to the person’s age (Barkley, 1998). The symptoms start between the age of six and twelve. Although minors are the most affected, some adolescents and adults as well suffer from the disorder.
At primary school stage, a child with ADHD has different behaviors from that of his/her age mates. The child is likely to fail academically due to learning and concentration problems. Inattention causes the child to miss the details from the teachers and when assignment’s instructions are issued resulting in poor academic performance.
The attention of a child with ADHD is paid to everything that happens around them rather than focusing on importance matters. Since children with ADHD are often stubborn and impatient, they are likely to be rejected by their peers, which result to low self esteem (Gilbert et al., 2005).
During adolescence, an ADHD patient may reduce over activeness, but inattention, impulsiveness, and inner restlessness continue. At this stage, they may develop a deformed self sense that disrupts the normal self development.
They may develop antisocial behaviors and excessive aggressiveness, which complicates the condition. Again, they are likely to fail academically, drop out of school, have teenage pregnancy, and get involved in substance abuse (Gilbert et al., 2005).
Bipolar disorder, also called manic is the most costly mental disorder. It is a brain illness classified by psychiatrists as a mood disorder. Also known as manic-depressive illness, people with this mood disorders exhibit behaviors with unusual shifts in moods and energy.
Recent studies have demonstrated a co-occurrence in bipolar disorder and ADHD, in children. Psychiatrists and clinicians have demonstrated consistent patterns that illuminate the relationship between ADHD and bipolar disorder.
Patterns show similar symptoms between the two illnesses. The main symptoms noted include irritability experiences between mania and depression episodes, disordered speech, attention and action. Irritability experiences are related to the neurodevelopment of the child while mania disorders are connected to psychiatric mood disorders.
More studies also show the existence of a two-way relationship between ADHD and bipolar disorder. Studied cases exhibit patterns of high rates of bipolar disorder in children with ADHD and vice versa. The complexity in co-occurrence of the two illnesses makes it strong to differentiate children suffering from ADHD from those with bipolar disorder. Several studies offer possible justifications on the dual diagnosis of bipolar disorder and ADHD.
Clinical examination on children with comorbidity bipolar and ADHD confirm that the two have distinct variances. Children with bipolar disorder display behavior characteristic of violence, temper, and prolonged temper outburst. Studies reveal that irritability observed in bipolar children is not severe, and its natural cause in pediatric cases is chronic and continuous and not acute.
Literature Review
Method
A literature review of published medical journals was carried to identify common cohort studies of adolescents and children with ADHD and bipolar disorder. The review mainly focused on research studies that examined the symptom relationship in ADHD and BDP children, and theories of comorbidity origins.
The research included the following terms in the review: “prospective” or “potential” or “upcoming” relationships” of “ADHD” and “bipolar disorder” or “mania” in “children” or “juvenile” and “comorbidity”, “implications” and “treatment”.
Results
Data was reviewed from 10 studies published between 1990 and 2013. Most of the studies uncovered the existence of treatment, genetics and family relationships between bipolar disorder and ADHD. Studies also revealed patterns of high rates of bipolar disorder in children with ADHD and vice versa.
Therefore, there is sufficient information to support research questions that guide this report. Let us scrutinize data that authenticate or rebut dual diagnosis of ADHD and bipolar disorder in children.
Bipolar symptoms lead to over-diagnosis of ADHD in children with bipolar disorder
Numerous investigations have yielded results insinuating that ADHD is common in bipolar children due to the exhibition of similar symptoms such as attention, distraction, hyper activeness, and poor sleep.
These findings explain the existence of high comorbidity rates between ADHD and bipolar due to overlapping diagnostic standards between the two disorders. Further, the findings confirm the state independence of the disorders depending on the rate and effects of bipolar in patients (Wozniak, 2003).
Milberger et al. (1995) adopted a subtraction method to ascertain whether similar diagnostic measures explained the elevated comorbidity rates between ADHD and bipolar disorder. This method involved deducting similar symptoms and applying similar principles to remaining symptoms. Statistics from the survey indicated that 100 percent of 15 children displayed co-occurring features.
This suggested that comorbid ADHD formed due to overlapping symptoms between bipolar and ADHD. Results from the subtraction method showed that 45% of the children retained bipolar diagnosis while those from the proportion method showed 80%. From the effects, it is clear that, in some patients with ADHD and bipolar disorder, comorbid bipolar disorder arises as a consequence of similar symptoms between ADHD and bipolar.
Wozniak (2003) notes that the symptoms of ADHD and bipolar can be distinguished from each other by distinguishing prototype symptoms using comorbid and consecutive samples. One major method employed to distinguish ADHD symptoms of bipolar is the utilization of semi structured questionnaires repeatedly in bipolar and ADHD patients.
A study by Geller et al., (2002) revealed behavioral symptoms such as euphoria, decrease in sleep, quick thoughts, and high sexual desires excluding distractibility and hyperactivity were frequent in youth with BPD in contrast to those with ADHD.
The findings further revealed that clinical characteristics could distinguish ADHD from bipolar disorder. The findings showed that ADHD children exhibited symptoms that lacked euphoria and psychotic features before they turned 7, a characteristic that was rare in children with bipolar disorder.
In their distinct forms, bipolar disorder and ADHD have distinguishing symptoms. Bipolar disorder presents euphoric and extreme irritable behaviors.
Findings propose that irritability is a common manic mood symptom in children and adolescents (Wozniak, 2003; Burke, 1997). Episodes define bipolar disorder and are useful indicators of mania. Similar symptoms exhibited by individuals with bipolar and ADHD make the two illnesses overdiagnosed or underdiagnosed.
Investigators propose the commonness of ADHD to bipolar disorder because both conditions exhibit common symptoms including and not limited to poor sleep, agitation, distraction and attention. As a result, symptoms associated with both the conditions explain a high comorbidity relationship between ADHD, mania and depression.
Further, exhibited symptoms explain the independence of ADHD changes on mania, euthymia and depressed children. Many children do not exhibit periods of major depression and mania. In fact, the few examples that show such symptoms do not endure for long but rather days or weeks.
Further studies indicate that classic sleep changes and elevated levels of productivity do not affect children. Many children diagnosed with bipolar disorder, neither exhibit depressive symptoms like hopelessness, low productivity, and poor self image, nor do they exhibit ADHD symptoms such as impulsivity and hyperactivity. Symptoms exhibited are more constant than episodic to be referred to as bipolar disorder.
Over diagnosed children present symptoms of explosiveness, irritability, impulsivity, inflexibility, and hyperactivity. Clinicians and psychiatrists have device different methods of differentiating ADHD from bipolar disorder, among them the use of validated rating scales (Fristad et al., 1995). This method used the youth mania rating scale by comparing scores. This included the measuring of greater symptom severity observed in manic patients.
ADHD is a prior expression of bipolar disorder diagnosis in children
Investigations have yielded results insinuating that ADHD is a prior expression of bipolar diagnosis in children resulting in high rates of comorbidity between the two illnesses.
Therefore, these findings explain why children with early-onset bipolar disorder have higher ADHD rates as compared to bipolar onset in adolescents and adults. Farther, the findings corroborate that the onset of bipolar in patients with bipolar disorder and ADHD occurs at an early age as compared to bipolar individuals without ADHD.
Many investigators have noted the relationship between age onset of bipolar and comorbid ADHD. Studies on co-occurrence of ADHD in bipolar adolescents and children carried out on by Wozniak et al. (1995) established that 90% children had ADHD, and only 57% adolescents had co-occurring ADHD.
Faraone et al. (1997) weighed ADHD in adolescents with childhood bipolar onset and those with adolescent onset. Findings reported high rates of co-occurring ADHD in bipolar children, mild in adolescents with childhood bipolar onset and lower in adolescents with adolescent bipolar onset.
More studies concluded that there high rates of mutual ADHD were present in pre- teenage mania, bipolar disorder, contrary to adolescent and commencing adult, bipolar disorder. The co-occurrence of ADHD and bipolar was ever present, unlike in adolescents.
In a demonstration of 56 adults with bipolar disorder, a study found that the age of commencing of the first sentimental event was younger for subjects with ADHD unlike those without such background (Sachs & Baldassano, 2000).
Elsewhere, Miyahara, Nierenberg, and Spence, (2005) discovered that ADHD overall lifetime mutual that patients with bipolar disorder and ADHD had started disposition turmoil 5 years compared to those with bipolar disorder without ADHD.
An adjustment of age onset of bipolar and ADHD patients worsened bipolar course, and increased rates of comorbid psychiatric disorders compared to patients with ADHD. Follow up studies conducted revealed that ADHD reduced with the increase in age (Faraone et al., 2006).
A recent review established bidirectional relationships between ADHD and bipolar disorder. Statistics showed that ADHD occurred in 85% of children with bipolar disorder while bipolar disorder occurred in 22% of children with ADHD (Singh et al).
From the statistics, there was a high occurrence rate of ADHD in bipolar disorder cases. Other statistical studies indicated that, in a child population with bipolar disorder, the rates of co-occurring ADHD ranged from 57% – 98% (Miyahara, Nierenberg, & Spence, 2005).
A research conducted to prove the co-occurrence of ADHD and bipolar disorder in children demonstrated a combination of disorders that met the criteria for both ADHD and bipolar disorder. Findings further revealed that persons with childhood onset bipolar risked getting ADHD than persons with adolescent bipolar disorder (Bielderman, Faraone, & Milberger, 1997).
Consequently, there were high chances of bipolar and ADHD comorbidity that did not result from shared diagnosis. Similar results from studies conducted by West, McElroy, & Strakowski (1995) indicated that preadolescent samples of ADHD in bipolar were higher than those of adolescents.
Therefore, the results suggest that ADHD co-occurs with pre-adolescence-onset bipolar. A lot of literature seems to support the theory that ADHD is a prior expression of bipolar diagnosis in children. There is explicit evidence that bipolar children experience high ADHD rates compared to adolescents.
ADHD and other linked factors lead to bipolar disorder diagnosis in children
Can the development of bipolar disorder be accredited to ADHD treatment? Diagnostic challenges caused by the co-occurrence of ADHD and bipolar disorder lead to medical administration of psychostimulants. According to Wozniak et al. (2004), clinicians use stimulants in treating children suffering from ADHD, and with fanatic symptoms.
Biederman, Newcorn, and Spencer (1998) observed that, children with bipolar disorder in their early stages were commonly treated with psychostimulants. However, some studies indicate that stimulants not only increase but also improve fanatic symptoms (Clower, 1998).
So far, no negative implications of using stimulants in children with ADHD, However, there is a need to be cautious on their application to bipolar disorder children since the actual effects have not been established (Carlson,1992). A research found out that, in every thirty four cases of hospitalized bipolar teenage girls, more than half had been subjected to stimulants in their younger stages of life (DelBello et al., 2001).
The study also found out that a majority of the teenagers had an intake of two or even more stimulating medication. This suggested that early exposure to more than one stimulant at the early stages could cause early diagnosis of bipolar disorder.
A similar study sampled eighty hospitalized teenagers with fanatic and combined incidences of bipolar disorder and ADHD. Observations revealed the existence of high levels of ADHD comorbidity that could not be fully accounted for due to exposure of the stimulant (DelBello et al., 2001).
In an effort to clarify the findings, more studies established that long exposure of stimulants to children and environmental stress led to a population of children that was genetically vulnerable (Strakowsi & DelBello, 2000).
Studies that demonstrated a chart analysis of bipolar children and adolescents proposed that continuous use of stimulant and other mood stabilizers improved ADHD symptoms when compared to treatment with stimulants before mood stabilizers in children and adolescents with co-occurring ADHD and bipolar disorder (Biederman, 1998).
Different studies have showed the exposure of psychostimulants and other factors associated with ADHD as precipitators of bipolar symptoms in children. There is a need for prospect studies to enhance more insights on short-term and long-term effects of brain exposure to stimulants.
Summary of Findings
It is evident that clinicians could be biased in diagnosing ADHD and bipolar disorder especially in children. Similarities in symptoms exhibited makes accurate diagnosis to a child with ADHD and mood imbalances hard.
Research in occurrence, assessment, genetics and treatment may assist in making diagnosis and medication decisions. From this report, we draw some diagnosis and treatment procedures and give clinical suggestions that highlight important areas for future research.
Recommendations
Diagnosis
For effective diagnosis, the following factors should be observed:
Use clinical equipments
For effective diagnosis, it is important to use special tools designed for primary care and evaluation of suspected cases of ADHD. The Vanderbilt assessment scale and SNAP-IV teacher and parenting scale for children with ADHD contain guiding questions that help in identifying defiant disorders and psychological disorders.
Screening tools would also help in examining behavioral, cognitive and emotional patterns and in so doing identifying cases that need more investigation.
Establish risk factors
For effective diagnosis, it is important to recognize the importance of establishing environmental risk factors. Children with known risk factors exhibit coexisting opposition defiant disorder. Therefore, by establishing risk factors, clinicians are able to determine the reason behind a certain behavior.
For example, a child’s family history is an environmental risk factor that should be recognized. From the family history, one can determine conduct disorders, antisocial personalities and oppositional defiant behavior. The history and nature of behavior should also be established.
Determine the nature of behavior
Behaviors are associated with growth and human development. It is important to determine the rate of abnormality in a child’s behavior. The only distinguishing factor between ADHD and bipolar in children is the degree and duration of behavioral mechanisms.
The cause of oppositional behavior should be identified. It is also important to assess a child and provide respective diagnosis to them as well as to the family and social support system when necessary. The assessment should be factual and in most cases involves information gathered from the child, school and parents. However, for a child to satisfy to meet the criteria for exhibiting bipolar disorder symptoms, the frequency of their behavior should be more frequent.
Make referrals when necessary
Effective diagnosis includes making of referrals when necessary. For complicated cases where diagnosis is not clear, referrals are made. Referrals should be made to qualified people with adequate training on mental and behavioral disorders in children. This ensures that the child gets professional help from trained personnel.
Treatment
There is a need to administer proper medication to bipolar children. Doctors should be very cautious and avoid using antidepressants. This is because children mostly show symptoms related to depression rather than bipolar.
Children with bipolar symptoms exhibit behaviors that reflect depressive moods. As a result, too much depressant may be used on a child. It is advised that before administering any depressants to children even those without bipolar, one needs to work very closely with family members. This is because many of these children suffer from ADH need stimulant medication tests that are stopped bipolar disorder is diagnosed.
There are three main methods of treating bipolar disorder. These are non pharmacologic treatment, preventive and pharmacological treatment.
Pharmacologic treatment
Research statistics indicate that some medicines are quite effective in ADHD treatment. These include, atomoxetine, (Strattera) methylphenidate also called Ritalin, dextroamphetamine, (Adderall), amphetamine.( Biederman et al., 2005, Newcorn et al., 2007).
Studies show that stimulants help in reducing the symptoms of oppositional defiance and ADHD. This is mostly through augmentation therapy or monotherapy (Connor, Barkley, & Davis, 2000, Hazell & Stuart, 2003). However, scientists have not shown that stimulant can reduce the oppositional defiance disorder when ADHD is not present.
Non pharmacologic treatment
When it comes to Non pharmacologic treatment, research has shown that there is a need to support and treat psychological problems even when the affected oppositional defiant children are at home.
In fact, the studies have identified recommended parental training as one of the best treatments for children with disruptive behavior (Farmer et al., 2002). During the training, parents are advised to be moderate when disciplining children, and more importantly they should be positive minded (Webster & Hammond, 1997).
The training sessions, which have proven to be effective, are mostly through the media. In essence, research has observed that, for best results, both children and parents must be involved in therapy, with an aim solving the problems jointly (Webster & Hammond, 1997). There also community based therapies like collaborative and multi systematic therapies that try to intervene and challenges in the society.
Prevention
In the treatment of co-occurring ADHD and bipolar disorder, prevention is highly recommended. In fact, there is sufficient evident that attests that the programs that are undertaken in the early institutions of learning especially elementary schools are of great benefit to prevention of the bipolar disorder. The other program that is helpful preventive program is the Incredible Years parenting.
All these preventive strategies depend on family support, multimedia and parenting skills. These strategies are self directed and are aimed at changing and preventing the problems associated with the children’ behavior.
The strategies are recommended for parents whose children showing behavior or emotional issues. In addition, school programs that encourage cohesiveness, anti bullying, social activities and peer groups are highly recommended as preventive approaches (Burke, Birmaher, Loeber, & 2002).
The family doctor can easily notice the disorder associated with opposition and defiance when a parent explains. This is a case where a child is very hostile, argumentative and exceedingly defiant. Oppositional defiant disorder mostly affects children with ADHD. In most cases, the disorder is likely to be traced from family history, especially due to financial constrain. Immediate diagnosis may require children to checked by a psychologist
It is important to note that for a doctor to identify disorder symptoms in a child, the family should be financially stable. A physician would need sufficient resources to achieve best results. Financial constraints hinder parents from providing multiple treatment methods. Motivation is a very important aspect for the children.
Conclusion
Even though debates exist on the comorbidity of ADHD, facts from different studies make the topic clear. This has led to application of appropriate diagnosis procedures identifying co-occurring conditions. Clinician and psychiatrists have devised effective application of pharmacological and behavioral interventions as treatment procedures.
However, it is important to note that more needs to be done in terms of sustaining suitable and fitting treatments to achieve long-term results. So far, diagnosis of bipolar in children has created awareness of the neurologic nature that children face. The challenges posed are significant and psychological sphere faces a great challenge in their efforts to help such cases
Directions for Future Research
Relationships between bipolar disorder and ADHD have complicated their treatment. So far, most of the explanations explored in the study play a part in explaining the common diagnosis of bipolar and ADHD in people.
Although the occurrence varies from individuals and age, this co-occurrence has created complex natures in their treatment. Researchers have so far made progress in understanding the mutual relationship between bipolar disorder and ADHD.
The use of rating scales and other instruments to assess the degree of behaviors have indeed confirmed the co-occurrence of ADHD and bipolar in individuals. Additionally, more studies have identified underlying biological characteristics in both bipolar and ADHD.
Although there is progress in understanding comorbidity of bipolar and ADHD, more studies on preventive and treatment strategies need to be developed. Research areas to be developed could include:
- The identification of suitable and reliable instruments to assess the degree of ADHD effect in children and monitor their improvement
- Identification of more advanced medications and therapies for clinical use such as electroencephalographic biofeedback
- The development and evaluation of effectiveness of school based interventions
- Development of preventive and monitoring methods of both parents and children aimed at improving their care both behaviorally and medically.
- Device comparison methods of medications depending to age and level of diagnosis
- The long term outcomes of co-occurrence of ADHD and bipolar in children
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