View Full Version : Differentiating AD/HD from Bipolar Disorder In Children

07-29-05, 09:27 PM
Differentiating AD/HD from Bipolar Disorder In Children

"The clinical features of children with ADHD and mania that lead to their psychiatric hospitalization indicate the presence of mania, not ADHD. These children are not admitted because of failure to complete homework.” ....Dr. Joseph Biederman

Hyperactivity, impulsivity, and inattention are seen in children with AD/HD and Bipolar Disorder, but these two disorders are radically different in terms of the impact that they have on a child’s life. Determining what is causing child’s behavior problems is extremely important. AD/HD is far less severe an impairment than Bipolar Disorder. The most important things for an AD/HD child to learn are how to slow down, focus, and organize his life. The most important thing for a child with Bipolar Disorder to learn is how to manage his mood shift from potentially destructive hypomania, to a depression so dark that it can be paralyzing or suicidal.

It may be difficult to distinguish Bipolar Disorder from AD/HD. Ninety-eight percent of children with the diagnosis of Bipolar Disorder also qualify for the diagnosis of AD/HD because of the presence of inattention, impulsivity, and hyperactivity seen in the attention deficit population (Biederman 2000). Conversely, twenty-two percent of those children diagnosed with AD/HD fit the criteria for Bipolar Disorder (Butler 1995). It is extremely important that this second group of kids with the dual diagnosis be identified so that they may receive proper treatment.

Many children diagnosed with Bipolar Disorder after puberty were diagnosed as AD/HD in the elementary school years. For these kids, the symptoms of impulsivity and craving for stimulation that they experienced before high school now take on the more troubling forms of hypomania and depression as Bipolar Disorder emerges. These children may have been Bipolar all along or they may have developed Bipolar Disorder at age eight or nine but were undetected as suffering from an affective disorder until later.

Some percentage of children and teens with the diagnosis of AD/HD experience challenges that are difficult to distinguish from those seen in Bipolar Disorder. The predilection for dangerous, destructive, and risky behavior; the abuse of substances and other addictive behavior, characterize some teenagers with AD/HD. Or these behaviors may indicate the presence of Bipolar Disorder in its manic phase. It may be unclear where the simply “disinhibited” behavior of AD/HD leaves off and where the cyclic manic phase of BD picks up.

Seven criteria for differentiating AD/HD from BD
It is important to know if a child is suffering from Bipolar Disorder, AD/HD, or both in a comorbid condition. Different medication, home management, and psychotherapeutic approaches are indicated depending on the condition and harm can be done if, for example, AD/HD medication is used to treat Bipolar Disorder Here are seven criteria for differentiating these two conditions:

1. Are mood shifts or the "aggressive depression" mixed-state present?
If a child has episodes of mania or depression or shows the mixed state aggressive depression typical of early-onset Bipolar Disorder, there is a good chance that the diagnosis of BD may be in order. Though the moods of children with AD/HD may be mercurial, especially when these kids hit their teens, they do not show the severe highs and lows of Bipolar Disorder or the violent expression that can occur in the mixed-state rapid cycling variety which afflicts younger children. AD/HD children may experience discomfort and demonstrate considerable irritability during medication rebound, but they are not chronically irritable as are children with Bipolar Disorder. And they do not usually show the behavioral extremes seen in BD when they are in medication rebound. They do not become over aroused and go screaming off into the darkness as do some kids with the powerful dysphoric hyperarousal of Bipolar Disorder. They do not attack their parents in blind rage. There is a noticeable difference in degree.

2. Does he have first degree family members diagnosed with Bipolar Disorder or other affective disorders?
A meticulous study of his family history is very important for making the AD/HD-Bipolar distinction. Children with Bipolar Disorder often have the condition in their immediate family, siblings, parents, grandparents, especially if they are diagnosed at an early age. This is an indication that affective disorder may exist in the family line. If it does, there is a high probability that it will be passed on (Goodwin and Jamison 1990).

3. Is his speech pressured or hypomanic?
Analyze the quality of a child's verbal output to determine if Bipolar Disorder or AD/HD is on board. Pressured speech seen in BD is known by its outpouring of words on continually shifting topics that may have little relationship to each other. The child's speech is powered by a flight of ideas, a jumble of thoughts, a thought- powered free association in which he will not appear to be listening to others and in fact may interrupt them continually to deliver his monologue. AD/HD’rs may talk too much and too loudly but they can be redirected and their verbal delivery can be slowed by a request from the listener such as “You’re going too fast for me and I’m getting breathless just listening to you.” This same request to a child with Bipolar Disorder may cause him to pause for about two seconds and then he will resume his monologue where he left off. If pressured speech occurs with other challenges associated with Bipolar Disorder, it is a good idea to assess if it is an aspect of hypomania and thus indicative of the Bipolar presentation. (Wagner, 2000)

4. Is dangerous and risky behavior a result of impulsivity or hypomania?
The dysinhibition of AD/HD is most often seen as a random search for stimulation in any form—be it through danger sports, drugs, gambling, sex, or illegal behavior. Though addictive opportunities are compelling to the AD/HD teen, the quality of hypomania is not present as it is for the BD teenager. For the BD teen, dysinhibition and stimulus craving can take over the child’s personality, and be directed with a purposeful energy in which he does not seem to need sleep and can power himself energetically toward a goal for several days. He may run away from home in the family car to pursue some wild flight of fancy and stay away for days, only to return exhausted and sleep for 20 hours straight. He may become fascinated by some pet interest and be unable to attend to anything else but that interest day and night for a week or two—dropping everything to go hunting for magic mushrooms, becoming fixated on an interactive game on the Internet with other kids, or steal his parents credit card number and spend hundreds of dollars sampling every kind of porn available on the net or cable TV.

5. Does he rage (Bipolar Disorder) or does he get angry (AD/HD)?
In Bipolar Disorder, rage is present from an early age. It may come up at the drop of a hat. Once it is engaged, it is unstoppable. It will go on for over half an hour. It can be violent, and it often results in exhaustion and rage state specific amnesia. The child may report feeling pleasantly energized by rage. He may hate what happens when he is enraged but he is drawn to the feeling of it (Popper, 1989). AD/HD children will get enraged because of frustration or simple hot temperedness. AD/HD children do not rage on a consistent basis as do children in the mixed state of aggressive depression seen in BD. And they do not generally get pleasantly energized by it nor do they experience state specific amnesia of what they did when enraged. They lack the expressed malevolence of the Bipolar child who may deliberately attack someone in a fit of rage and try to hurt them. It is important to identify the severity of a child’s rage.

6. Is psychotic activity--hallucinations and severe thought distortion-- in evidence?
The child with AD/HD may demonstrate extreme silliness and show a profound lack of common sense because of his inability to focus on things and make good decisions. But AD/HD children generally do not have hallucinations. The child with affective illness, on the other hand, may experience visual hallucinations that are very disturbing to him. Many children with Bipolar challenges tell me about these hallucinations though they are loathe to discuss these with others for fear of being labeled crazy. Some evaluators now see the presence of visual hallucinations as indicative of Bipolar Disorder and auditory hallucinations as indicative of schizophrenia (Hendren, 2000). AD/HD children can be extremely oppositional. But most of them are able to eventually see their own involvement in problem situations. The child with Bipolar Disorder is unlikely to admit his part in the issue even when confronted with evidence to the contrary. It is as if a “cognitive hallucination” is present that blocks his perception of reality. Unlike the AD/HD child, who will most likely end up as the underdog in an encounter with parents, defending himself from some accusation of wrongdoing, the child with Bipolar Disorder will take the offensive. He will attempt to impose his will on the family at all costs.

7. Does he show other aspects of Bipolar Disorder such as the nighttime hyperarousal pattern, anempathy, and Conduct Disorder?
There are some additional challenges that Bipolar children typically have that AD/HD’rs don’t.
Nighttime hyperarousal is sometimes seen in AD/HD and is usually a medication side-effect or the inability of the person to calm his sense of AD/HD "driveness." The Bipolar child comes alive at night when his brain levels of serotonin, the “civilizing” neurotransmitter, is at a 24 hour low. He may become a very nasty character and go into full-blown fits of rage or attempt to tyrannize everyone in the family.

Many Bipolar children are anempathetic. They do not understand the feelings of others and may show shallow affect themselves. AD/HD children tend to be supersensitive to the feelings of others when they can stop long enough to pay attention to them. AD/HD kids wear their hearts on their sleeves. This is part of their challenge and charm. Children with Bipolar Disorder may show cruelty and be very circumspect when it comes to their own feelings.

bMany children with Bipolar challenges will also qualify for the Conduct Disorder diagnosis (312.82) with its list of law-breaking, crimes against people and animals, and lack of remorse. Though AD/HD'rs do have a greater chance of being diagnosed with CD than unaffected kids, they do not show the high percentage of comorbidity (69%) that is seen in the pediatric BD population (Kovacs and Pollack 1995)..

Checklist of differences between Bipolar Disorder and AD/HD
1. Presence of mood shift or mixed state of aggressive-depression
2. A family history of affective illness
3. Pressured speech or hypomania are present
4. Dangerous behavior occurs in hypomanic phase
5. Presence of rage (Bipolar Disorder) or anger (AD/HD)?
6. Presence of hallucinations, severe thought distortion, and tyrannical behavior.
7. Other Bipolar challenges are present such as anempathy and Conduct Disorder.

Early correct diagnosis can save a child’s life Dr. Joseph Biederman (Biederman, 2000) maintains that there is a serious lack of knowledge among diagnosticians about how to diagnose the presence of Bipolar Disorder. He points to research on the “kindling” effect of depression to show how misdiagnosis can hurt a child. The kindling effect is seen in the damage the brain incurs as it is weakened by depression over time. The first depression may be bad, but because it has happened, the next one is worse.

If a child presents with a mixed-state, rapid cycling early onset Bipolar Disorder and is misdiagnosed “severe AD/HD” and given stimulants, he may be thrown into a manic frenzy. Or the misdiagnosis can result in the child not receiving medical treatment for his depression. Ignoring this problem makes it worse.

If a child is comorbid with both AD/HD and Bipolar Disorder, it may be possible to use stimulant medication or antidepressant medication, but the child's mood disorder must first be stabilized using a mood stabilizer such as lithium carbonate or a newer generation anti-convulsant such as valproic acid (b. Depakote) .

Goodwin and Jamison assert that 15 to 20 percent of those with Bipolar Disorder kill themselves (1990) The misery that these people experience makes AD/HD look comfortably tolerable. Misdiagnosis of the child with Bipolar Disorder can do him great damage because it not only cuts him off from help appropriate to his illness, but sets the stage for his isolation from his community. It is this sense of being alone in an uncaring universe that drives a kid to consider ending his own life. This is a tragedy preventable with the right diagnosis at the right time.

07-29-05, 09:37 PM
Is it Bipolar Discorder, ADHD, or What?

by Annette Lansford, MD

The differential diagnosis and comorbidity of bipolar disorder, mania and adhd.


The prevalence of child and adolescent manic depression (bipolar disorder) is said to affect 1% of youth, with equal rates of boys and girls and may be increasing. The diagnosis of bipolar disorder in youth is often very difficult, as the symptoms typically do not follow the symptoms and course of adults with this disorder. Also, there is an overlap of symptoms with several other more common childhood disorders.


Bipolar disorder is a severe mental illness manifested by recurrent episodes of depression, mania and/or mixed symptom states. Children and some adolescents show a much greater percentage of mixed symptoms, expressing both depressive and manic behaviors at the same time (agitated dysphoria) or rapidly fluctuating moods. Children most commonly present with a mixed and dysphoric picture, characterized by frequent short periods of intense emotional ability and irritability rather than classic euphoria. Bipolar disorder beginning in childhood or early adolescence may be a more severe illness than in older adolescent or adult onset disease.


In late adolescents with bipolar disorder, the most common mistaken diagnoses are schizophrenia and conduct disorder. Attention deficit hyperactivity disorder has been the main differential problem in prepubertal and early adolescent patients. The difficulty in distinguishing these two disorders is due to the high prevalence of coexisting ADHD among childhood onset bipolar patients and from the overlap of certain DSM-IV criteria for mania and ADHD (hyperactivity, distractibility and impulsivity). Although irritability is one of the most frequent symptoms of mania/hypomania in all ages, it is of little help in the differential diagnosis in children because of its ubiquity across a number of childhood diagnoses, including mania, major depressive disorder, ADHD, autism, and oppositional defiant/conduct disorders. Only a small percentage of children with irritability have mania.


The differentiation of mania from ADHD is difficult. The response or lack of response to stimulant medications is not diagnostically helpful. Elevated mood and grandiosity are the symptoms best able to distinguish between pediatric bipolar disorder and ADHD. With bipolar disorder, hyperactivity may be more episodic. However, ADHD may be the first manifestation of mania and is often comorbid with mania in children. An overwhelming majority of manic youth also have ADHD. Almost one quarter of youth with ADHD meet the criteria for mania. Prepubertal onset bipolar disorder is a nonspecific chronic rapid cycling mixed manic state that may co-occur with ADHD and conduct disorder or have features of ADHD and/or conduct disorder as the initial manifestation. The high rate of comorbidity of ADHD with bipolar disorder may be an age dependent child manifestation that will decrease with age. The onset of bipolar disorder in patients with a history of ADHD is often between 11 and 12 years of age. Many children who develop bipolar disorder develop a depressive disorder first. Of youth with major depression, up to 1/3 go on to develop mania/bipolar disorder.


Mania in children is seldom characterized by euphoric mood; the most common mood disturbance is severe irritability with "affective storms" (prolonged and aggressive temper outbursts). In between outbursts, these children are described as persistently irritable or angry. Manic children often have a decreased need for sleep-not insomnia, but an ability to function well on less sleep than normal. These children frequently receive a diagnosis of conduct disorder. Aggressive symptoms may be the primary reason for the high rate of psychiatric hospitalizations in manic children.


Children are incapable of presenting many manifestations of bipolar symptoms described in adults. Studies have shown that five behavioral symptoms in children/early adolescents aid in correctly diagnosing childhood bipolar disorder. These manic symptoms which do not overlap with ADHD are elation, grandiosity, flight of ideas/racing thoughts, a decreased need for sleep, and hypersexuality (in the in absence of sexual abuse or overstimulation). These five symptoms provide the best discrimination of childhood/early onset bipolar patients from uncomplicated ADHD patients. Irritability, hyperactivity, accelerated speech and distractibility are frequent in both pediatric bipolar disorder and ADHD and are not useful in differentiating between the two disorders. Mixed mania (simultaneous mania and depression) is highly prevalent in childhood bipolar disorder.


Many children with bipolar disorder are described by the parents as having had a difficult temperament in infancy. Great caution should be used in making a diagnose of bipolar disorder in a young child with no family history of psychiatric illness because of the difficulties in the diagnosis in young children with this disorder. Bullying may be a developmental age specific manifestation of grandiosity.


When bipolar disorder begins before or soon after puberty, it is often manifested by continuous rapid cycling irritablily and mixed symptoms, which may co-occur with disruptive behavior disorders. The ultradian (essentially continuous) rapid cycling/ mixed state is one in which children switch in and out of depression, irritable mania with explosions and euphoric mania unpredictably and throughout the day, almost everyday, with very little time spent in a regular age appropriate mood state.


The hypersexuality associated with mania can mimic the self stimulatory and sexual acting out behaviors associated with children who have been abused or have witnessed adult sexual behavior. There is a risk of over diagnosis of bipolar disorder in children with conduct disorder and ADHD. The manic rating scale (Fristad, Weller and Weller) has acceptable validity and reliability and can help distinguish between manic and hyperactive children. (Fristad, Weller and Weller(1995) The Manic Rating Scale(MRS): Further reliability and validity studies with children. Ann clin Psychiatry 7: 127-132.


The treatment of ADHD in early bipolar disorder is controversial. Concern has been expressed about the use of psychostimulants to treat ADHD in children with mania and these drugs potential risk for triggering affective episodes in vulnerable children. Clinical experience to date, however, suggests that stimulants, in combination with one or more mood stabilizers, seem to be safe and effective in the treatment of children with mania complicated by ADHD and may result in improvement of the ADHD. When the diagnosis of bipolar disorder has been made, the management of these complex children involves ongoing assessment and, frequently, the use of a combination of medications, requiring expertise and experience in dealing with this type of patient. As the bipolar child goes into adolescence, a turbulent and risk taking time, psychiatric management is indicated.


The course of bipolar disorder in children and adolescents is typically a relapsing recurring illness with substantial morbidity. A US self help organization, the Child and Adolescent Bipolar Foundation, has a web site for parents, which offers helpful information to families raising children or teens with early onset bipolar disorder.

Annette Lansford, M.D., FAAP, a sub-board certified developmental behavioral pediatrician in private practice at Carle Clinic in Urbana,IL. She is the medical director of the Carle Child Disability Clinic, an intradisciplinary diagnostic clinic. She is a clinical associate professor of Pediatrics at the University of Illinois School of Medicine at Urbana-Champaign.

08-18-05, 09:22 AM
This is extremely informational and helpful! Thank you so much for taking the time to do this.

10-21-05, 11:30 PM
Thank you so much for that information. I can better understand my son's rapid changing mood swings. Mine too for that matter. Now is the big do you control the fits of outrage, and what do you do when they are having a "fit"?

10-22-05, 06:21 AM
Can you control fits of outrage? It may simply be better to have a place, a routine in place. This is where he goes when he gets like that. Through trial and error you can find out what works best.

03-31-10, 03:05 PM
Can you control fits of outrage? It may simply be better to have a place, a routine in place. This is where he goes when he gets like that. Through trial and error you can find out what works best.

Try this method: It works for our daughter.

When the Rage occurs... DO NOT RESPOND! Turn, and leave the room. if you are followed, walk outside. Do not acknowledge the rage, or try and talk them down. Remove yourself from the situation. Even if things are being broken, thrown, or your respect is questioned. No matter what, dont say anything, turn, and walk out.

The trick is when your child happy and calm, and playful, let them know that whenever he/she gets mad next time, that this is going to happen Blach blah. That when they eventually calm down, and ask appropiately, you will be happy to discuss things with them, but not before, no matter what. With mine, I tell her that if she ever needs or wants attention, I will be happy to give her a hug if she needs one, or asks me for one. Thats the kind of attention I will give her, but not positive or negative when an outburst happens.

It does work, and it works quickly. My 10 yr daughter now has rage outburts, and it is so short and brief now. Now she has her 'moment' and then she cries... she will come up to me and tell me she needs a hug. Then I hold her, but only because she then wants to be held, not because I am holding her down. <-- that is a huge mistake and will eventually make your problem worse.

04-20-10, 03:44 AM
I agree with the conversation leads to differentiation between AD and HD type.Bipolar disorder is a severe mental illness manifested by recurrent episodes of depression, mania and/or mixed symptom states. Children and some adolescents show a much greater percentage of mixed symptoms, expressing both depressive and manic behaviors at the same time (agitated dysphoria) or rapidly fluctuating moods. Children most commonly present with a mixed and dysphoric picture, characterized by frequent short periods of intense emotional ability and irritability rather than classic euphoria. Bipolar disorder beginning in childhood or early adolescence may be a more severe illness than in older adolescent or adult onset disease.