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After reading this article, readers should be able to:
• Better appreciate the familial role in ADHD
• Recognize the implications of ADHD and bipolar comorbidity
• Understand the overlapping psychopathology and diagnostic issues associated with ADHD and bipolar comorbidity
• Comprehend the psychopharmacological response in comorbid ADHD and bipolar disorder
• Initiate a treatment strategy that may include mood stabilizers and stimulant medications
Who will benefit from reading this article?
Psychiatrists, child and adolescent psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals.
Is bipolar disorder overdiagnosed in youths? Public and scientific debates have focused on the controversial topic of whether some children with emotional and behavioral problems are receiving an incorrect diagnosis of bipolar disorder and are being exposed unnecessarily to the adverse effects of mood stabilizing medications.On the other hand, it may be that because of skepticism and diagnostic confusion, bipolar disorder has been, and continues to be, underdiagnosed in youths, with many children left untreated despite FDA approval of potentially useful medications for children as young as 10 years.Thus, efforts to better understand the issues of diagnostic confusion are of extremely high clinical, scientific, and public health importance.
A major component of the debate regarding the validity of the diagnosis of bipolar disorder in youths rests with its high overlap with ADHD.1 Distractibility, physical hyperactivity, and talkativeness are symptoms of both ADHD and mania. Arguably, all the symptoms of ADHD, including inattention, impatience, disorganization, and restlessness, could be part of the mania component of bipolar disorder.
By the same token, many of the symptoms of mania, such as euphoria (giddy, silly) or irritability (low frustration tolerance), reckless impulsivity, and racing thoughts, could be construed to occur at least some of the time as part of ADHD.2 ADHD also can include a component of emotional dysregulation, which further complicates the diagnosis.3
Epidemiology of ADHD and bipolar disorder
While not all training programs include education in pediatric bipolar disorder, all child and adolescent psychiatry residents and most pediatricians are well acquainted with the diagnosis of ADHD, which is one of the most common reasons for psychiatric treatment in pediatric patients. ADHD is a highly morbid, well-characterized, and valid disorder with onset in childhood; it affects more than 5% of youths.
While bipolar disorder in adults has long been considered to be one of the most disabling conditions seen in psychiatric practice, the condition in children has only recently been the focus of research to establish its validity. Because of a lack of accurate epidemiological reports, researchers had estimated, based on indirect evidence, that bipolar disorder affects approximately 1% of children and adolescents. However, a recent epidemiological study of more than 10,000 US adolescents reports a rate of 2.9% (2.6% are severely impaired).4
A recent meta-analysis performed by Van Meter and colleagues5 of international epidemiological studies of pediatric bipolar disorder from 1985 through 2007 showed an overall prevalence of 1.8%. The researchers noted that there was no significant difference in the rates between US and non-US studies, and there was no evidence of an increase in the community over time.
While mania can present as either euphoria or extreme irritability, findings suggest that irritability may be the more common manic mood symptom in youths.6,7 While a case can be made that the irritability of mania is distinctly and qualitatively different from other forms of irritability, when present in a child with ADHD, irritability or angry outbursts may be misattributed to the frustration of living with ADHD and attendant impulsivity rather than to co-occurring mania.8 Conversely, inattention, distractibility, and talkative-ness in a child or adolescent with bipolar disorder may erroneously be attributed to residual mania rather than ADHD.
According to diagnostic criteria, episodicity is a definitional feature of bipolar disorder and can be a useful marker of mania, just as chronicity or cross-situationality is a diagnostic feature of ADHD. However, the documented chronicity and complex/rapid cycling of bipolar disorder in youths often renders the notion of classic episodicity as a distinguishing feature of mania functionally impracticable.9 While many adults with bipolar disorder present with chronicity, mixed states, and irritability as the clinical picture, this presentation has been the subject of debate when it occurs in children.6 Whether this presentation is valid for bipolar disorder for some patients remains a scientific and clinical question.
In clinical practice, the question of whether mood-dysregulated, hyperactive, and inattentive youths have bipolar disorder, ADHD, or both has critical clinical and therapeutic implications. Medications for ADHD may worsen mania, and medications for mania are fraught with adverse effects and may not be effective for the treatment of ADHD. Because ADHD and mania exhibit similar symptoms, there is a risk of unintentional overdiagnosis or underdiagnosis of one or the other. Milberger and colleagues1 demonstrated that most of the children in their study with the combined disorders continued to meet criteria for both mania and ADHD after overlapping symptoms were discounted. This suggests that bipolar disorder and ADHD comorbidity is not a methodological artifact that results from shared diagnostic criteria.
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