Bipolar Disorder and ADHD: Diagnosis and Treatment Issues
by David Gottlieb, Ph.D. and Thomas Shoaf, MD

Bipolar disorder and ADHD can occur together inchildren but the dual disorder is difficult to diagnose and treat. One of the problems is making an accurate diagnosis. Clinicians have not yet agreed on the criteria that are primary in mania in preadolescent children. One aim of this article is to propose a tentative classification scheme for pediatric mania. Subsequently, the authors explain why it is important to determine whether these children have characteristics of ADHD as well. After looking at diagnostic issues, the authors outline treatment strategies, both medical and psychological, for bipolar disorder when it occurs along with ADHD. Treatment of bipolar disorder in children is still in its infancy, and treatment of the dual diagnosis with ADHD is even newer.The dual diagnosis is difficult to treat and requires a team approach: the psychiatrist, psychologist, teachers, and parents need to communicate with each other and work together to help these children develop self?ontrol.

Bipolar disorder has been traditionally thought of as a disorder that affects adults,rather than children. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM?V, 1994), maniain adults usually lasts several days or longer, and three or four of the following criteria need to be present to a significant degree: 1. inflated self?steem or grandiosity 2. decreased need for sleep 3. more talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractibility 6. increase in goal?irected activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences.

Geller and colleagues (Geller, Williams, Zimerman, Frazier, Beringer, & Warner, 1998) have been studying the occurrence of mania in children and point out a number of differences in pediatric mania compared to adult mania. First, there is usually rapid cycling in children, such that manic episodes may last minutes or hours,rather than days. Further, a number of these episodes of mania often occur during a single day.

Two primary characteristics of pediatric mania are grandiosity and elated mood. Geller found that these two features are key symptoms because they occur in 85% of bipolar children but do not occur to a significant degree withother disorders, like ADHD. Other characteristics, such as racing thoughts, hypersexuality, and decreased need for sleep, occurred in about half of manic children but did not occur often with other diagnoses. Because these characteristics occur in only half of pediatric cases of mania, they are important, but not truly defining features of the disorder. Likewise, other features examined by Geller and colleagues, such as daredevil acts and uninhibited people seeking, are important to look for,but these are not by themselves defining characteristics of ma- nia because they occur in children who have other diagnoses, such as ADHD.