Problem 4
PART 1 LEARNING GOALS
Can children/young people (or even babies) also suffer from bipolar disorder?
How does this differ from adults?
What is the difference between manic features and ADHD?
Can we distinguish it (BP) from other diseases?
How could you treat depression in children?
MARANGONI ET AL – BIPOLAR DISORDER AND ADHD: COMORBIDITY AND DIAGNOSTIC
DISTINCTIONS
Intro
- BD and ADHD often co-occur
- ADHD is defined by early onset of symptoms of inattention and/or hyperactivity and
impulsivity, causing impairment in at least 2 settings (home and school)
- ADHD and BD account for a large proportion of prescriptions of stimulants,
antipsychotic / mood stabilizing agents in preschoolers
differential diagnosis of ADHD and BD
- no established biomarkers
- rely on clinical observation and parental/school reporting
- challenges to differential diagnosis: non-episodic course of BD, limited ability to self-
report in pediatric samples, symptomatic overlap, reciprocal comorbidity, similar
psychiatric comorbidities (anxiety, mood disorders, substance use disorder)
- most difficult when ADHD is comorbid with conduct disorder or oppositional defiant
disorder bc their presentation (temper tantrum, aggressive behavior) can overlap
with symptoms of manic or mixed episodes
Epidemiology
- prevalence of ADHD: 1.7% to 16% in school age youths and 1-5% in adults, ADHD
symptoms persist into adulthood
- BD lifetime prevalence: 2.1% in adults and 1.8% in children
- both disorders are more prevalent in males
- BD youths suffer from comorbid disorders (anxiety, ADHD, disruptive behavior,
substance use)
- ADHD comorbid with CD, ODD, anxiety or SUD increase risk of developing later BD
- children with ADHD have an increased risk of comorbid BD
Clinical features: 3 approaches to differentiate ADHD from BP
o eliminating overlapping symptoms:
but cases free of psychotic, suicidal or hyper-sexual behavior still
remains difficult to distinguish
o use the chronological appearance of symptoms on a developmental
continuum
, useful to identify symptoms that’re likely to distinguish the two
disorders at an early age
o Child Behavior Checklist
mixed results
, Differences in specific symptoms
Hyperactivity
- BD: intense hyperactivity, agitation, increased drive, insomnia, grandiosity etc.,
there can also be periods of low activity, exhaustion and boredom
- ADHD: increased restlessness, fidgeting, and hyperactive behavior especially in
activities that require focus and prolonged effort
- BD: greater fluctuations of energy, “eveningness”
- ADHD: relatively stable levels of activity compared to BD
Disturbances of sleep and circadian rhythms
- BD: ultra-rapid cycling, increased daytime & nighttime hyperactivity, early +
middle + late insomnia (the whole night), parasomnias, decreased need for sleep
- ADHD: early insomnia, fatigue the next day (BD: they’re not fatigue)
- both: sleep resistance
Mood, suicidality and psychosis
- BD: mood symptoms (irritability, dysphoria, crying spells, temper tantrums)
- ADHD: mood symptoms are secondary to social or academic difficulties
- suicidality is seen in both ADHD and BD
- psychosis and delusions are seen in BD but not in ADHD
Aggressive and hypersexual behavior
- BD: severe temper tantrums, deliberate or planned aggression
- ADHD: verbal and physical aggression can result from irritability, destruction of
property is accidental
- hypersexual behavior is common in BD but not in ADHD
Academic functioning
- ADHD: inattention, resistance, poor concentration interferes with school
- BD: more variable uneven performance
Family History
- BD: most significant risk factor is family history
- ADHD: twin studies also indicate there’s a heritability risk of 60-80%
Course
- evidence that both BD and ADHD can be under-, over- or misdiagnosed
- in cases where the symptoms are below the diagnostic threshold, the clinical should
determine:
o that a sign/symptom represents a change from baseline
o that it’s not explained by situational factors
o that it’s not due solely to developmental delay
o that it follows an independent course
- BD:
- majority experience temperamental mood symptoms long before their first episode
- usually follows a chronic course of alternating syndromal and subsyndromal phases
with symptom-free intervals
- requirement of periodicity to diagnose BD sometimes results in misdiagnosis in those
with chronic, non-episodic course
- ADHD:
- follows a chronic and unremitting course
PART 1 LEARNING GOALS
Can children/young people (or even babies) also suffer from bipolar disorder?
How does this differ from adults?
What is the difference between manic features and ADHD?
Can we distinguish it (BP) from other diseases?
How could you treat depression in children?
MARANGONI ET AL – BIPOLAR DISORDER AND ADHD: COMORBIDITY AND DIAGNOSTIC
DISTINCTIONS
Intro
- BD and ADHD often co-occur
- ADHD is defined by early onset of symptoms of inattention and/or hyperactivity and
impulsivity, causing impairment in at least 2 settings (home and school)
- ADHD and BD account for a large proportion of prescriptions of stimulants,
antipsychotic / mood stabilizing agents in preschoolers
differential diagnosis of ADHD and BD
- no established biomarkers
- rely on clinical observation and parental/school reporting
- challenges to differential diagnosis: non-episodic course of BD, limited ability to self-
report in pediatric samples, symptomatic overlap, reciprocal comorbidity, similar
psychiatric comorbidities (anxiety, mood disorders, substance use disorder)
- most difficult when ADHD is comorbid with conduct disorder or oppositional defiant
disorder bc their presentation (temper tantrum, aggressive behavior) can overlap
with symptoms of manic or mixed episodes
Epidemiology
- prevalence of ADHD: 1.7% to 16% in school age youths and 1-5% in adults, ADHD
symptoms persist into adulthood
- BD lifetime prevalence: 2.1% in adults and 1.8% in children
- both disorders are more prevalent in males
- BD youths suffer from comorbid disorders (anxiety, ADHD, disruptive behavior,
substance use)
- ADHD comorbid with CD, ODD, anxiety or SUD increase risk of developing later BD
- children with ADHD have an increased risk of comorbid BD
Clinical features: 3 approaches to differentiate ADHD from BP
o eliminating overlapping symptoms:
but cases free of psychotic, suicidal or hyper-sexual behavior still
remains difficult to distinguish
o use the chronological appearance of symptoms on a developmental
continuum
, useful to identify symptoms that’re likely to distinguish the two
disorders at an early age
o Child Behavior Checklist
mixed results
, Differences in specific symptoms
Hyperactivity
- BD: intense hyperactivity, agitation, increased drive, insomnia, grandiosity etc.,
there can also be periods of low activity, exhaustion and boredom
- ADHD: increased restlessness, fidgeting, and hyperactive behavior especially in
activities that require focus and prolonged effort
- BD: greater fluctuations of energy, “eveningness”
- ADHD: relatively stable levels of activity compared to BD
Disturbances of sleep and circadian rhythms
- BD: ultra-rapid cycling, increased daytime & nighttime hyperactivity, early +
middle + late insomnia (the whole night), parasomnias, decreased need for sleep
- ADHD: early insomnia, fatigue the next day (BD: they’re not fatigue)
- both: sleep resistance
Mood, suicidality and psychosis
- BD: mood symptoms (irritability, dysphoria, crying spells, temper tantrums)
- ADHD: mood symptoms are secondary to social or academic difficulties
- suicidality is seen in both ADHD and BD
- psychosis and delusions are seen in BD but not in ADHD
Aggressive and hypersexual behavior
- BD: severe temper tantrums, deliberate or planned aggression
- ADHD: verbal and physical aggression can result from irritability, destruction of
property is accidental
- hypersexual behavior is common in BD but not in ADHD
Academic functioning
- ADHD: inattention, resistance, poor concentration interferes with school
- BD: more variable uneven performance
Family History
- BD: most significant risk factor is family history
- ADHD: twin studies also indicate there’s a heritability risk of 60-80%
Course
- evidence that both BD and ADHD can be under-, over- or misdiagnosed
- in cases where the symptoms are below the diagnostic threshold, the clinical should
determine:
o that a sign/symptom represents a change from baseline
o that it’s not explained by situational factors
o that it’s not due solely to developmental delay
o that it follows an independent course
- BD:
- majority experience temperamental mood symptoms long before their first episode
- usually follows a chronic course of alternating syndromal and subsyndromal phases
with symptom-free intervals
- requirement of periodicity to diagnose BD sometimes results in misdiagnosis in those
with chronic, non-episodic course
- ADHD:
- follows a chronic and unremitting course
