Is It ADHD or Bipolar Disorder?

Children with bipolar disorder are often misdiagnosed as having ADHD, and ADHD medication won't help. Sometimes, children suffer from both.


Reviewed By Brunilda Nazario, MD

When Alex Raeburn was in the fourth grade, he started having discipline problems and occasional outbursts in school. Toward the end of his fifth grade year, he stormed out of the classroom, broke the glass face of a hall clock, then left the school building entirely. The incident landed him in the psychiatric ward of a hospital where he underwent testing, but he left without a diagnosis.

Alex's problems continued, so his parents took him to see a psychiatrist who had been recommended by his school's psychologist. "This doctor talked to my wife and I for 15 minutes, then to Alex for 15 minutes, diagnosed him with ADHD (attention deficit hyperactivity disorder) and put him on Ritalin," says Paul Raeburn, who wrote a book about his son's experiences entitled Acquainted with the Night. When there was no improvement after a few weeks on the medication, the doctor suggested increasing Alex's dose.

"After we increased the dose, Alex became completely out of control, very volatile and angry," Raeburn tells WebMD. "He threatened to run out of the house and not come back, so we had to hospitalize him again."

It was during this hospital stay that bipolar disorder was first suggested as a possible diagnosis instead of ADHD. Eventually, it was confirmed that Alex indeed suffered from bipolar disorder and that the Ritalin had most likely triggered his violent episode.

Because ADHD and bipolar disorder do share some symptoms and sometimes coexist, children like Alex are commonly misdiagnosed. ADHD is a more common condition in children and often the first thing a doctor thinks of.

"One problem is that there are not many child psychiatrists in this country, so parents take their child to a pediatrician, who just isn't equipped to do a comprehensive assessment, says J. Kim Penberthy, PhD, a professor in the department of psychiatric medicine at the University of Virginia. "Instead, a quick and dirty job of diagnosing is done."

According to the National Institute of Mental Health, bipolar disorder is difficult to recognize and diagnose in youths because it does not fit typical symptoms seen for adults.

Research done by Joseph Biederman, MD, a child psychiatrist and expert in bipolar disorder in children, estimates the frequency of ADHD in school-aged kids at 3%-5%. The frequency of bipolar disorder in the same group is estimated to be less than half of 1%. Most of the children diagnosed with bipolar disorder also meet the criteria for ADHD, while only about one in five with ADHD meet bipolar disorder criteria.

Some experts believe that ADHD is overdiagnosed, and while bipolar disorder is relatively rare in children, it tends to be underdiagnosed. This could be because bipolar disorder typically surfaces in adolescence or early adulthood, and it is much less black-and-white in terms of how it manifests in children.

Current research suggests that there may in fact be a third, separate disorder that is somewhere in between the two.

Symptoms present in both ADHD and bipolar disorder include impulsivity, inattention, and hyperactivity, and both disorders seem to be inheritable.

But there are many differences, the biggest being that bipolar disorder is primarily a mood disorder, while ADHD affects attention and behavior. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of ADHD, conduct disorder, oppositional defiant disorder, or other types of mental disorders.


Key Differences Between ADHD, Bipolar Disorder

A few other key ways in which they differ include:

How anger manifests itself. Though both ADHD and bipolar disorder have an anger component, the tantrums of a kid with ADHD are usually born out of frustration or overstimulation; any destructiveness is also unintentional and a result of carelessness.

With a bipolar child, anger is explosive and extreme and usually triggered when a parent or other authority figure attempts to set limits; destructiveness is often intentional. A kid with bipolar disorder can sustain his rage for as long as two hours, whereas one with ADHD can usually be calmed down within 20-30 minutes.

Whether or not psychosis is present. "With bipolar disorder, a large number of kids have psychosis, meaning thoughts and behaviors not based in reality," says Stephanie Hamarman, MD. "For example, a child might really believe he has superpowers and can fly. ADHD kids do not exhibit psychosis." Hamarman is chief of psychiatry at the Stanley Lamm Institute of Long Island College Hospital in Brooklyn, N.Y.

How consistent the behaviors are. ADHD symptoms tend to be chronic, while bipolar disorder is generally more episodic. ADHD tends to improve over time; bipolar disorder often gets worse, especially if proper treatment is delayed.

Treating these illnesses routinely starts with mood-stabilizing medications. Studies are looking into the effectiveness of other forms of therapy like psychotherapy. In ADHD, treatment may require stimulant or newer nonstimulant medications. When both disorders are present, the mood component is treated first. Studies are looking into the effectiveness of other forms of therapy like psychotherapy for these conditions.

"The most important thing is for parents to get their child a thorough diagnostic evaluation," Penberthy tells WebMD. "That means the doctor doesn't just talk to the person who brings the child in, but gets info from multiple sources, including teachers, Little League coaches, peers, and daycare providers."

With either disorder, the earlier you catch it, the better. Proper diagnosis and treatment not only reduces the impairment in functioning due to symptoms, but it hopefully prevents the long-term effects that may occur if the disorder is untreated.

"Research shows that having ADHD symptoms in childhood can have negative effects in adolescence and adulthood, such as substance abuse, low academic achievement, interpersonal conflicts, low self-esteem, and high physical injury rates," says Penberthy.

Untreated bipolar disorder can result in a phenomenon known as "kindling," where each episode has the effect of setting the stage for future episodes, which may worsen over time. In the case of bipolar disorder and ADHD together, there is an even greater need for careful and accurate diagnosis, since the stimulant medications that can successfully treat ADHD may actually worsen manic symptoms of bipolar disorder.

Parents also play a big role and need to be persistent in finding knowledgeable doctors and challenging them if they think their child is misdiagnosed. Even under ideal circumstances, finding the right combination of medications, especially with bipolar disorder, requires some trial and error.

Joyce (who asked that her last name not be used) went through years of misdiagnoses and incorrect treatments with her son, Shane, starting when he was 7 years old. Shane is bipolar and experienced several episodes involving mania, depression, and violence before getting his illness under control.

"He's almost 12 now, and it's taken us until this year to get the correct combination and dosage of medication," she says. "He'll never be 'normal' and will always need medication, but to anyone who doesn't know him, they now see a typical boy full of life, charm, and a kind heart."

Published Jan. 10, 2005.
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SOURCES: J. Kim Penberthy, PhD, assistant professor, department of psychiatric medicine, University of Virginia. Stephanie Hamarman, MD, chief of psychiatry, Stanley Lamm Institute of Long Island College Hospital, Brooklyn, N.Y. Differentiating ADHD From Bipolar disorder in Children, George T. Lynn, MA, MPA, LMHC. National Institute of Mental health.

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Monday, February 28, 2005
Guidelines to assist bipolar kids
Local researcher drafts changes

By Tim Bonfield
Enquirer staff writer

ABOUT BIPOLAR DISORDER
Bipolar disorder (also known as manic-depression) is a disorder of the brain marked by extreme changes in mood, energy, thinking and behavior. Symptoms may be present since infancy or early childhood, or may suddenly emerge in adolescence or adulthood.

Experts suspect that some children diagnosed with attention-deficit disorder or clinical depression may actually have early-onset bipolar disorder.

Bipolar disorder can often be managed with medication, psychotherapy and lifestyle changes such as stress reduction, regular sleep, accommodations at school, and avoiding caffeine, alcohol, and drugs.

The new treatment guidelines will appear in the March issue of the Journal of the American Academy of Child and Adolescent Psychiatry. They already are available on the journal's Web site at www.jaacap.com

Source: Child & Adolescent Bipolar Foundation

A new set of guidelines for treating children with bipolar disorder to be published next month will allow parents to check whether their children are getting the best treatment.

And a local researcher played a central role in developing them.

The guidelines are designed to help doctors diagnose bipolar disorder (which also is known as manic depression) in children ages 6 to 17.

The guidelines are the first in years to suggest when and how to use a variety of newer medications in combination with the traditional counseling.

"Doctors are getting somewhat better at recognizing bipolar disorder in children, but there wasn't much to guide them in terms of treatment," said Dr. Robert Kowatch, director of the Pediatric Mood Disorders Center at Cincinnati Children's Hospital Medical Center.

Dr. Kowatch led a group of experts to draft the guidelines in an effort sponsored by the Child & Adolescent Bipolar Foundation.

Bipolar disorder affects about 1 to 2 percent of adults nationwide, but not much is known about how many teens and younger children also suffer the condition.

Symptoms of bipolar disorder include grandiose delusions, irritable mood often accompanied by aggression and self-injury, decreased need for sleep without daytime fatigue, speech that is difficult to interrupt, racing thoughts, and in some cases, hearing voices.

Many children can be too suicidal, too manic or too depressed to attend school. It often takes a combination of treatments to stabilize them for that, Kowatch said.

A big problem with diagnosing the condition is that many bipolar children also suffer from other problems, including attention-deficit disorder with hyperactivity (ADHD), anxiety and substance abuse.

The new guidelines represent a consensus of existing research results and clinical experience, said Dr. Mina Dulcan, editor-in-chief of the adolescent psychiatry journal.

"Far too little research has been done on the treatment of bipolar disorder in youth," Dulcan said. "We hope that the guidelines will not only facilitate clinical care but also inform and enhance new research."

E-mail tbonfield@enquirer.com
Enquirer staff writer


ABOUT BIPOLAR DISORDER
Bipolar disorder (also known as manic-depression) is a disorder of the brain marked by extreme changes in mood, energy, thinking and behavior. Symptoms may be present since infancy or early childhood, or may suddenly emerge in adolescence or adulthood.

Experts suspect that some children diagnosed with attention-deficit disorder or clinical depression may actually have early-onset bipolar disorder.

Bipolar disorder can often be managed with medication, psychotherapy and lifestyle changes such as stress reduction, regular sleep, accommodations at school, and avoiding caffeine, alcohol, and drugs.

The new treatment guidelines will appear in the March issue of the Journal of the American Academy of Child and Adolescent Psychiatry. They already are available on the journal's Web site at   American Academy of Child and Adolescent Psychiatry
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Copyright 2005, The Cincinnati Enquirer

The Lingering Legacies of ADHD
By Carol Marie Cropper
Fri May 27, 8:06 AM ET



Two new studies of girls and boys with attention deficit hyperactivity disorder (ADHD) indicate a dramatic increase in their risk of acquiring such afflictions as major depression, bipolar disorder, and drug addiction.

The longitudinal studies took place at Massachusetts General Hospital in Boston, a teaching facility for     Harvard Medical School. They tracked the development of various disorders in boys ages 12 to 22, over 10 years, and in girls between 12 and 17 for for 5 years. The results of the studies were presented on May 26 at the American Psychiatric Assn. annual meeting in Atlanta.

BIPOLAR RISK. Compared with a control group, girls with ADHD showed a nineteenfold increase in the odds of experiencing a major depression by age 17. About 46% of the 123 girls with ADHD had a depressive episode, compared with only about 3% of a 112-member control group. The girls with ADHD were 15 times as likely to have developed bipolar disorder, and more than 4 times as likely to suffer from drug dependency.

Meanwhile, about 46% of the 112 boys with ADHD in a separate study experienced major depression by age 22, vs. 7% of a 105-member control group. They were about 8 times more likely to have developed bipolar disorder and twice as apt to have become dependent on drugs.

"Children with ADHD, when they reach adult shores, have a very high risk for a wide range of adverse outcomes," says Dr. Joseph Biederman, a Harvard Medical School professor and lead researcher in the studies.

GIRLS, TOO. Adult attention disorders cost the U.S. $77 billion annually, Biederman says.  

In the U.S., about 5% of girls, and 10% of boys, ages 5 to 18 suffer from ADHD, Biederman says. Many observers had assumed that girls did not develop some of the problems boys did, according to Biederman. "Girls with ADHD tend to be underdiagnosed and undertreated." But, he says, people should consider ADHD a serious problem for juvenile females as well as males. It's not just a question of why "Johnny" can't sit still anymore.

Researchers identify bipolar disorder in preschoolers

By Jim Dryden

Dec. 9, 2005 — Child psychiatry researchers at Washington University School of Medicine in St. Louis have identified a small group of preschoolers who appear to suffer from bipolar disorder, also known as manic-depressive illness. The findings, presented this fall at the annual meeting of the American Academy of Child and Adolescent Psychiatry, highlight symptoms that distinguish bipolar disorder from other mental health problems in very young children.
Mania can be confused with attention deficit hyperactivity disorder.


This chart compares levels of impairment in young children. The purple bar represents bipolar children. The red bar shows impairment in young children with clinical depression. The white bar shows children with attention deficit hyperactivity disorder. Finally, the blue bar indicates children with no psychiatric symptoms.


Diagnosing bipolar disorder in children is difficult because the manic phase of the illness can be confused with the more common attention deficit hyperactivity disorder (ADHD). The confusion arises because mania and ADHD both involve hyperactivity, irritability and distractibility. These issues may be even more difficult in young children who display some of these behaviors and emotions normally. However, Joan Luby, M.D., an associate professor of child psychiatry, found mania symptoms, as defined by psychiatry's Diagnostic and Statistical Manual (DSM-IV), did not occur in healthy preschoolers and that three main symptoms distinguished bipolar disorder from ADHD in preschoolers: elation, grandiosity and hypersexuality.

Similar to the mania symptoms in older bipolar children — first outlined by Barbara Geller, M.D., professor of child psychiatry at Washington University School of Medicine — young children who manifested elation, grandiosity and hypersexuality had dramatically higher odds of having bipolar disorder when compared to children with ADHD.

"This is different than the ordinary, energetic state of young children, even children with ADHD," Luby explains. "When you ask healthy young children what they're capable of doing, they are known to inflate their capabilities and say they can run very fast or jump very high or even fly like Superman. What's different about grandiose children is that they become delusional and actually believe they can do things like run the preschool. An extreme example that I've seen involved a manic preschooler who believed that she made the sun rise and set."
This chart compares levels of impairment in young children. The purple bar represents bipolar children. The red bar shows impairment in young children with clinical depression. The white bar shows children with attention deficit hyperactivity disorder. Finally, the blue bar indicates children with no psychiatric symptoms.
This chart compares levels of impairment in young children. The purple bar represents bipolar children. The red bar shows impairment in young children with clinical depression. The white bar shows children with attention deficit hyperactivity disorder. Finally, the blue bar indicates children with no psychiatric symptoms.

During the manic phase of the illness children may experience exceedingly high self-esteem, an inflated sense of power or ability or may act as though they are in charge at home or school. They may act extremely happy, silly and giddy, but their moods can change rapidly. A decreased need for sleep and excessive chatter also are common. Some bipolar children even experience depression at the same time.

In 2003, Luby and colleagues were the first to identify clinical depression in preschoolers. In this new study, Luby's team attempted to distinguish children with bipolar disorder from those who were clinically depressed by looking for evidence of mania. They studied a community sample of 305 children between the ages of 3 and 6.

The researchers used a preschool age psychiatric interview developed at Duke University, called the PAPA, (Preschool Age Psychiatric Assessment) and added a mania module based on their experiences both with older bipolar children and with younger depressed preschoolers.

"We put together what we thought the symptoms of bipolar disorder would look like in younger children hoping both to learn whether very young children could actually have bipolar disorder and if so, whether we could distinguish it from other psychiatric disorders, particularly ADHD," Luby explains.

They also used a parent questionnaire and took advantage of special interview techniques, designed for young children, to identify signs and symptoms of depression and mania.

"One of the reasons this area of research has been slow to develop is that we've only recently learned how to ask very young children about their feelings," Luby says. "We use an age-appropriate puppet interview, in which we have two puppets converse with one another about how they feel and then ask the child to point to the puppet that best expresses his or her own emotion."

The team also observed children in various play schemes designed to induce a range of emotions — from joyful responses to frustration — and videotaped the children to obtain objective measures of their behavior. They also used story stems, in which children were given a scenario that presents some type of an emotional conflict. The researchers then asked the children to play out the story to its completion.

In all, 26 of the 305 children in the study met all DSM-IV diagnostic criteria for bipolar disorder, but because the sample was put together in such a way that depressed children and others with symptoms of disruptive disorders were much more likely to be studied than healthy children, Luby says the prevalence of bipolar disorder in preschoolers certainly is much lower than was reflected in this sample.

The study also had higher numbers of children with depression and ADHD than would be found in the general population so that the researchers could compare the disorders and detect differences that allow for more precise diagnosis. The ability to distinguish a problem like bipolar disorder from ADHD is critical because although the disorders share some symptoms and some children meet the diagnostic criteria for both disorders, Luby says treatment with stimulant medications that can help kids with ADHD can be problematic for children with bipolar disorder.
Joan Luby


How best to treat bipolar disorder remains an open question, not just for preschoolers but for older children, too. Although several effective treatments exist for adults, children often respond to medications differently. A National Institute of Mental Health (NIMH)-funded study called the TEAM (Treatment of Early Age Mania) treatment study currently is comparing the effectiveness of treatments in older children. At the national level, the multi-center TEAM study is being led by Barbara Geller, M.D., a pioneer in the recognition of bipolar disorder in children.

Washington University School of Medicine's Early Emotional Development Program is one of five sites participating in the TEAM study. Luby is the study's principal investigator at the St. Louis site.

Researchers are comparing how well different medications and medication combinations work in making bipolar children between the ages of 6 and 15 feel better. Qualified participants are randomly selected to receive either lithium, a drug commonly prescribed for adults with bipolar disorder; valproate, an anticonvulsant drug that has been related to improvement of manic symptoms in a few smaller studies; or risperidone, an antipsychotic medication used in adults with schizophrenia that also is being tested in children with autism.

"We hope that by comparing these drugs and drug combinations, we might be able to find better ways to control this severe illness in older, affected children, and as those results become available, we can look at whether these treatments also might help younger children." Luby says.

In another study, Washington University investigators are part of an international team zeroing in on the genetic causes of bipolar disorder. Following analysis of DNA from more than 5,000 people from more than 1,000 families, that study has found evidence suggesting a genetic linkage to regions on chromosomes 6 and 8. Those researchers are continuing to enroll bipolar adults 18 and older to further isolate the genes that may contribute to the debilitating disorder.

Someday, those findings may make it easier to identify adults and children at risk for bipolar disorder and to begin treatment sooner.

The Treatment of Early Age Mania (TEAM) study at Washington University is ongoing and currently recruiting children ages 6-15 with a diagnosis or symptoms of bipolar disorder to participate. For more information, please call study coordinator Samantha Blankenship, at (314) 286-2783.

For more information on the adult genetic study, call program manager Caroline Drain at (314) 286-1345 or toll-free at (866) 289-1378.

Luby JL, Heffelfinger AK, Mrakotsky C, Brown KM, Hessler MJ, Wallis JM, Spitznagel EL. The clinical picture of depression in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 42:3, pp. 340-348, March 1, 2003.

This research was supported by a grant from the National Institute of Mental Health of the National Institutes of Health to Dr. Luby

The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.

A Closer Examination of Bipolar Disorder in School-Age Children
(Professional School Counseling)
Updated: Oct 26th 2005

By Bard**k, Angela D; Bernes, Kerry B

Children who present with severe behavioral concerns may be diagnosed as having other commonly diagnosed childhood disorders, such as attention deficit hyperactivity disorder, oppositional defiant disorder, and/or conduct disorder, among others, when they may be suffering from early-onset bipolar disorder. Awareness of the symptoms of early-onset bipolar disorder may lead to appropriate referrals for assessment and treatment, as well as collaborative program planning for children with bipolar disorder. Implications and recommendations for school counselors are discussed.

Many teachers and parents are not sure where to turn when a child presents with severe behavioral concerns. Early-onset bipolar disorder is often difficult to recognize and diagnose because distinguishing between normal behaviors and pathological behaviors in children can be challenging, and because symptoms of bipolar disorder may resemble those of, and/or co-occur with, other common childhood-onset mental disorders (Bowring & Kovacs, 1992; National Institute of Mental Health [NIMH], 2000; Papolos & Papolos, 1999). NIMH (2000) emphasizes the importance of increased understanding and knowledge of the diagnosis and treatment of bipolar disorder in youth.

The American School Counselor Association (ASCA) recognizes that students diagnosed with psychological or behavioral problems will likely experience difficulties with performance at school, at home, and in the community. This article addresses difficulties with the diagnosis of bipolar disorder in children; provides a description of bipolar disorder in adults and children; presents a case study; discusses appropriate assessment, treatment, and program planning for children; and discusses implications and recommendations for school counselors according to the ASCA National Standards for School Counseling Programs.

Bipolar disorder in children often is misdiagnosed and misunderstood. The established criteria for bipolar disorder are based on adult symptoms, which vary greatly from children's symptoms (NIMH, 2000; Papolos & Papolos, 1999). Bipolar disorder often is overlooked because a majority of children with symptoms of bipolar disorder also may meet the criteria for more commonly known childhood disorders such as attention deficit hyperactivity disorder (ADHD) (NIMH; Popper, 1996), oppositional defiant disorder (ODD), and conduct disorder (CD) (Kovacs & Pollock, 1995; NIMH), as well as anxiety disorders (Bashir, Russell, & Johnson, 1987; Wozniak et al., 1995) and schizophrenia (Carlson, Fennig, & Bromet, 1994). Symptom overlap, especially with ADHD (Wozniak et al.), makes it difficult to obtain an accurate diagnosis and may result in treatment that worsens, rather than stabilizes, the disorder.

In order to understand how bipolar disorder may be more accurately assessed and diagnosed in children, we first must understand the symptoms of the disorder in adults, and then review how the presentation of the disorder differs in school-age children.

BIPOLAR DISORDER IN ADULTS

According to the Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), adults with bipolar disorder typically experience a pattern of mood swings ranging from hypomania or mania (which includes increased rates of thinking and activity, energy surges, heightened creativity and sexuality, and less need for sleep) to depression (which includes difficulty making decisions, sleep disturbances, low energy levels, lack of interest in sex, appetite disturbances, and difficulties with concentration and attention), with potential intervals of wellness between manic and depressive episodes (American Psychiatric Association, 2000). An adult experiencing a manic "high" may spend money impulsively, make reckless decisions, commit sexual indiscretions, and/or experience rapid mood swings. Bipolar I refers to individuals who experience depression alternating with out-of- control or psychotic mania, and Bipolar II refers to those who suffer depression and experience hypomanic episodes without loss of control or psychosis. According to the DSM-IV-TR, rapid cycling occurs if an individual experiences four or more episodes per year (American Psychiatric Association). Earlyonset bipolar disorder frequently presents very differently in children than bipolar disorder in adults.

BIPOLAR DISORDER IN CHILDREN

Children with early-onset bipolar disorder rarely fit the classical pattern of bipolar disorder in adults, so using adult criteria to diagnose children may result in a misdiagnosis. Children with early-onset bipolar disorder may present with a wide variety of symptoms that range from mild to extreme and that may begin as early as infancy (Papolos & Papolos, 1999). These may include irritability, unpredictability, hyperactivity and attention problems, conduct problems, social problems, childhood depression, eating disorders, self-mutilation, and suicidal ideation (NIMH, 2000; Papolos & Papolos).

Major depression may be one of the first manifestations of early- onset bipolar disorder. Studies have shown that approximately one third of children who first appear to be suffering from depression may later manifest symptoms of bipolar disorder (Geller, Fox, & Clark, 1994; Lewinsohn, Klein, & Seely, 1995; State, Altshuler, & Frye, 2002). Depression in children may appear as frequent crying, loss of interest in enjoyable activities, changes in appearance (e.g., lack of self-care), increased irritability, changes in sleeping patterns (e.g., too much or too little sleep), and increased social withdrawal (Papolos & Papolos, 1999).

Wozniak et al. (1995) states that severe irritability is often a predominant mood in children meeting the criteria for mania. Impending mania also may appear as an increase in behaviors such as being silly, giddy, goofy, or mouthy, having grandiose ideas (e.g., that they can teach better than the teacher), speaking rapidly, having racing thoughts, having bizarre hallucinations, making outrageous comments, and exhibiting hypersexuality (e.g., making sexualized comments) (Papolos & Papolos, 1999). Behavior may become very goal-directed (e.g., taking out materials to begin working on a project that must be completed immediately).

Mixed states and rapid cycling have been reported in over 70 percent of children diagnosed with earlyonset bipolar disorder (State et al., 2002). A mixed state is marked by agitation, high energy, and constant restlessness coupled with feelings of worthlessness and self-destruction (Papolos & Papolos, 1999). Rapid cycling is defined as rapid transitions between depressive and manic symptoms (American Psychiatric Association, 2000). Ultra-rapid cycling may last a few days to a few weeks, and ultradian (ultra- ultra-rapid) cycling may occur within a 24-hour period (Geller et al., 1998).

Many children with bipolar disorder exhibit symptoms associated with ADHD, such as distractibility, motor hyperactivity, and overtalkativeness (Hazell, Carr, Lewin, & Sly, 2003). It is not known whether these disorders may coexist, if hyperactivity precludes mania, or if there is symptom overlap (State et al., 2002). Faraone et al. (1997) suggested that, in some cases, ADHD may be an early marker of early-onset bipolar disorder. Geller and Luby (1997) reported that 90 percent of children and 30 percent of adolescents with bipolar disorder also may have ADHD. Biederman et al. (1996) found that the lifetime prevalence of bipolar disorder in a sample of children and adolescents with ADHD doubled over a 4- year period, increasing from 11 percent to 23 percent. Thus, it is important to note that although symptoms or a diagnosis of ADHD are present, something more than ADHD may be going on.

Children with early-onset bipolar disorder may exhibit symptoms associated with ODD or CD, such as defiance, refusal to comply with adults' requests, and deliberately annoying people (Kovacs & Pollock, 1995). Frequent lying and manipulation of others may be another comorbid symptom of bipolar disorder and ODD/CD (Papolos & Papolos, 1999). Geller and Luby (1997) found that approximately 22 percent of children and 18 percent of adolescents with bipolar disorder demonstrated features of CD, such as poor judgment and grandiose behaviors, as initial manifestations of early-onset bipolar disorder.

Substance abuse also may become a comorbid condition during the teenage years (Geller & Luby, 1997). Children with bipolar disorder also may experience intense cravings for carbohydrates and sweets. Many females suffering from bipolar disorder also suffer from coexisting eating disorders such as anorexia (self-induced starvation) or bulimia (bingeing and purging) (Bock, 1999).

Some children with bipolar disorder may have difficulty with peers because they are unable to respond appropriately to social clues or boundaries. Parents may describe their bipolar children as "bossy,""intrusive,""has to have his or her own way or the game is over," or "too overwhelming and aggressive" (Papolos & Papoplos, 1999, p. 18). Some children with bipolar disorder may rake their arms with razors, pins, or other sharp objects, hit themselves, or bang their heads against a wall in an attempt to self-mutilate (Papolos & Papolos). Probably the most dangerous symptom of bipolar disorder is suicida\l ideation, even in children as young as 4 years of age (Papolos & Papolos). There is a higher risk of suicidality among bipolar adolescents compared to adolescents with other diagnoses (Brent et al., 1993). Hospitalization may need to be considered if a child is so out of control that he or she is unable to stop raging, experiencing delusions or hallucinations, threatening to harm others, harming himself or herself, or threatening suicide. The high prevalence of suicidality combined with the rapidity of cycling means that serious suicidal risk may appear without warning (Geller et al., 1998).


The above-noted behaviors may be setting-specific. A child may act one way at home and another way at school, causing confusion for parents and teachers. The wide range of behavioral and mood-related symptoms associated with early-onset bipolar disorder, as discussed above, serves to complicate making an accurate diagnosis.

DIAGNOSIS

Children with bipolar disorder may be "among the most challenging children to diagnose" (State et al., 2002). There are no scales to rely on, no specific lab tests, a variety of overlapping symptoms with other psychiatric disorders, and a wide range of individual differences. Normal developmental symptoms and stages further affect problems with diagnosis (Papolos & Papolos, 1999). Medical conditions-such as diabetes, thyroid problems, iron-deficiency anemia, cancer, and chronic fatigue syndrome, among many others-may include symptoms that mimic depression or mania (Papolos & Papolos). Medical conditions such as these must be ruled out by a complete physical examination with laboratory tests. A complete medical exam, assessment by a child psychiatrist, family history, social history, selfreports, and observations of behavior are necessary to arrive at a diagnosis, and even then there may be a significant amount of ambiguity. Once a diagnosis has been made by an appropriate professional, early intervention is imperative.

EARLY INTERVENTION

Early intervention can help to stabilize children who experience overwhelming mood changes and rages as well as to provide hope for their future. As well, it is important to prevent other difficulties associated with adolescent bipolar disorder, such as engaging in risky behaviors, hypersexual behavior leading to unwanted pregnancy and/or sexually transmitted diseases, reckless driving, and the possibility of substance abuse (Papolos & Papolos, 1999). Early intervention helps families to obtain appropriate services and supports and to make plans for the future. Early intervention may lead to a diagnosis that explains much of the behavioral and emotional experiences of the child as well as guides treatment.

As an example of the importance of early intervention, a case study of a child recently diagnosed with early-onset bipolar disorder is examined.

CASE STUDY OF A 9-YEAR-OLD MALE

This male child was born after a full-term pregnancy and delivery by vacuum extraction. He was always at the 50th percentile for height and weight and met all developmental milestones within normal time limits. Behavior difficulties were first noted between the ages of 2 and 3, when he would yell and bang his head at day care, aggressively hit, kick, and bite others, and thrash around in a tantrum over something simple. Most of the time, he was enthusiastic, helpful, and constantly on the move, but he would fly into a rage over nothing within minutes.

This child continuously complained of headaches, stomach problems, and difficulty swallowing, and he had frequent diarrhea. At age 5, his family doctor referred him to a psychiatrist because of his behavior, who found that he met the criteria for ADHD and ODD. His school referred him for psychological testing, where it was found he was of average intelligence, with a giftedness in math. The psychologist also found that he had many symptoms associated with ADHD, impulsivity disorder, and severe ODD. His mother chose not to start him on Ritalin because of the risk of side effects.

His Individual Program Plans (individualized educational programs designed for students identified with cognitive or behavioral difficulties in Canadian schools) from kindergarten to Grade 3 consisted of strategies to work on anger management, cooperation, behavior, and reading, as well as enrichment activities for math. His teachers reported that his behavior gradually improved, but that he would become very anxious when completing timed math facts. At one time before completing timed math facts, he became so anxious that he began screaming and banging his head against the wall. He continuously worried about getting good grades, was often bossy on the playground, did not have many friends, and would become explosive in group activities. His stories were creative and consisted of dragons, blowing up the world, sea monsters, and constant conflict. He talked incessantly and with great detail.

He reported to the school counselor, and later to a social worker, that he had been spanked, threatened, yelled at, sworn at, and made to stay up all night doing hours of homework. In referring to living at home, he said that sometimes it was as bad as "Frankenstein having his head cut off and sewn back on and being brought back to life. Do that 100 times and that's how bad it is." As a result, he was taken into custody by a child protection worker because of concerns about physical and emotional abuse.

While in custody, he repeatedly ran away and exhibited more extreme behaviors. He threatened to kill the foster family's dog and to throw himself in front of a van, and he stated that if he had a knife or a gun he would "kill everyone then kill himself." His behavior became so extreme that he was hospitalized. After being released, he continued making threats to harm himself and others, banging his head against the wall, and needed to be restrained. He again was taken to the hospital but was refused admission because they would not deal with a child with behavioral problems, stating that he "needed some discipline," and that one could not take threats of suicide seriously from a 9-year-old child.

The mother voluntarily underwent a full parenting assessment, and none of the physical or emotional abuse concerns were substantiated. In response to her child's reports of physical abuse, she reported that he would punch and kick her, and she would restrain him and send him to his room. In response to his reports of being made to "stay up all night to do homework," she reported that she knew he was gifted in math, so she saw no reason for him to have difficulty with timed math facts and had him practice for a half hour each night.

It is understandable that this child's behaviors initially were attributed to ADHD and ODD; however, several clues were missed during the assessment and observation of this child. Despite his hyperactivity, he was able to focus on a project for 1 to 2 hours at a time. As well, he demonstrated extreme variety and vacillation of moods, or rapid cycling. His father was reported to have been diagnosed with bipolar disorder, and his mother had been diagnosed with major depression, which points to a bilateral transmission of the disorder. His ability to focus, rapid mood changes, and family history combined with years of behavior problems narrowed the diagnosis down to early-onset bipolar disorder. Fortunately for this child, appropriate pharmacological and psychotherapeutic treatment stabilized his moods and behaviors, allowing him to do well at school and at home.

IMPLICATIONS FOR SCHOOL COUNSELORS

When faced with a child who presents with severe behavioral problems, school counselors' primary roles center around the ASCA's National Standards in academic development and personal/social development. The following recommendations are based on the ASCA position on ADHD (ASCA, 2000) and recommended interventions for children with behavioral disorders. The school counselor may participate in the implementation of the following: (a) making referrals for appropriate assessment and treatment; (b) developing a collaborative relationship with parents and teachers so as to facilitate a multimodal delivery of services to children with bipolar disorder; © helping teachers design appropriate programs for students that include opportunities to learn appropriate social skills and self-management skills; (d) providing students with activities to improve their self-esteem and self-concept and to promote the safety of self and others; (e) and serving as a consultant and resource to parents, teachers, and other school personnel on the characteristics and problems of students with bipolar disorder.

School counselors need to be aware that children who present with severe behavioral concerns need to be thoroughly assessed and treated by a child psychiatrist and/or child psychologist. In these situations, the role of the school counselor is to encourage parents to have the child assessed so that appropriate provisions may be made at the school level to accommodate the child's needs. It is recommended that school counselors and teachers document dates and severity of behaviors that are a cause for concern in order to help appropriate health-care providers arrive at an accurate diagnosis. Continued documentation of behaviors after diagnosis and during treatment is important to monitor progress and to help fine-tune treatment requirements.

The development of a collaborative relationship among the school counselor, parents, and teachers is important for a plan for working with the bipolar child. Counselors may play a role in helping teachers give the child a sense of consistency throughout his or her day by maintaining open communication with parents to identify effective strategies to be used at both home and school. Working with parents and teachers to identify inciting events that may set off a child's negative behavior may be helpful in bot\h the home and school setting. For example, the child in the case example became easily frustrated when doing timed math facts at both home and school. When given the opportunity to complete math facts without the pressure of being timed, his frustration level dropped and he experienced success. A daily home-school communication log may become an important tool to ensure that everyone receives the same information and adjusts the child's schedule or work expectations accordingly. For example, if a child had a difficult time sleeping the previous night, it may be expected that he or she may not be functioning at an optimal level at school the next day. Therefore, providing the child with a quiet space to work, opportunities to take more breaks, or a reduced workload may be appropriate.

Children with bipolar disorder may be defiant and resistant to suggestions from adults, resulting in conflict. Greene (1996) has recommended that parents and teachers prioritize items into three "baskets" in order to reduce behavioral difficulties. The purpose of the baskets is to identify behaviors that are non-negotiable, negotiable, and not worth addressing. "Basket A" consists of non- negotiable items that parents and teachers should insist upon, such as unsafe behaviors that could be harmful to the child, other people, animals, or property (e.g., anything that requires a firm "No"). "Basket B" consists of items that are negotiable, that are important to teach the child how to stay calm in the midst of frustration, and that require the adult to work with the child to arrive at a mutually satisfactory resolution. Greene suggests using the question "Can you think of a way to work that out?" to encourage children to think about possible solutions, rather than overreacting to the problem. For example, completing timed math facts is not a safety issue (Basket A), therefore, it is negotiable (Basket B). The adult would calmly and rationally identify the reason for not wanting to complete timed math facts and negotiate with the child an appropriate manner in which to complete the math facts. "Basket C" consists of items that are not worth fighting about (e.g., no-win situations). For example, for some children in certain mood states, completing math facts may be a no-win situation, and therefore, the adult would not even address the situation until a later time.

Counselors need to recognize that the bipolar child's behaviors are stimulated by internal rather than external factors but may be easily set off by external cues (Papolos & Papolos, 1999). Therefore, children with bipolar disorder require special accommodations at school, specifically in regard to overstimulation, transitions, and social interactions (Papolos & Papolos). By developing a collaborative working relationship with parents and teachers, school counselors may be able to work with the classroom teacher to make accommodations for the child with bipolar disorder. School counselors may need to provide rationales for teachers for them to make necessary accommodations in their classrooms (explaining about internal and external factors that influence the student's behavior). For example, children who become overstimulated may require a place to calm down when their moods are variable. It is recommended that the child be given the opportunity to choose the times when he or she would prefer to work alone, or the child and teacher may develop a signal for use when either of them recognizes that difficulties may occur. Children who have difficulty making transitions may benefit from the use of a written plan for the day so they are aware of the transitions in advance. Children who have difficulty with social interactions may benefit from practicing skills such as staying calm in the midst of frustration, collaborative problem solving, and seeing situations from alternative viewpoints (Greene, 1996).

Personal safety and the safety of others is always an issue. Collaboration with administration, teachers, and parents is necessary to determine where a child will be taken if he or she is in a rage. Removing the child from the classroom or playground and into a space that is safe may be necessary. Some children respond well to being physically restrained by an individual trained in child restraints, whereas other children become more panicky. A child who is raging likely will not respond to verbal intervention by adults, and that child requires space and time to regain control and calm down (Papolos & Papolos, 1999). It is highly recommended to have a space reserved for children who may experience rages at school, such as a room with no stimulation and no access to materials that may become weapons (Greene, 1996; Papolos & Papolos).

It is difficult to know how seriously to take a child's threat of suicide (Papolos & Papolos, 1999). It is a myth that individuals who threaten suicide never actually go through with it, so any threat of suicide from a child of any age needs to be taken seriously. Suicide is often an impulsive act and may be triggered by a variety of events (e.g., relationship problems, difficulty with schoolwork, hurt feelings), so children who threaten suicide need to be closely monitored.

By developing a broad base of knowledge of bipolar disorder in children, the school counselor may act as a consultant or resource person for parents, teachers, and school personnel. Knowing the signs and symptoms associated with early-onset bipolar disorder would lead to appropriate referrals, assessment, and treatment. As a result, collaborative programming may ensue for children with academic, behavioral, and/or social problems associated with early- onset bipolar disorder.

CONCLUSION

Many children present with behavioral difficulties that may be misdiagnosed and misunderstood. Early-onset bipolar disorder is difficult to diagnose because symptoms overlap with other disorders as well as with normal childhood development. Increased awareness of the symptoms of a potential mood disorder in children may help school counselors refer children for appropriate assessment and treatment. School counselors need to be aware of the symptoms and implications of mood disorders in children, and to collaborate with parents and teachers to make accommodations at school to promote the safety, well-being, and success of the child with bipolar disorder.

Early-onset bipolar disorder is often difficult to recognize and diagnose because distinguishing between normal behaviors and pathological behaviors in children can be challenging.

Children with early-onset bipolar disorder rarely fit the classical pattern of bipolar disorder in adults, so using adult criteria to diagnose children may result in a misdiagnosis.

Mixed states and rapid cycling have been reported in over 70 percent of children diagnosed with early-onset bipolar disorder.

Early intervention can help to stabilize children who experience overwhelming mood changes and rages as well as to provide hope for their future.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American School Counselor Association. (2000). The professional school counselor and attention deficit/hyperactivity disorder: American School Counselor Association (ASCA) position. Retrieved July 27, 2004, from http://www.schoolcounselor.org/content. cfm?L1=1000&L2=4

Bashir, M., Russell, J., & Johnson, G. (1987). Bipolar affective disorder in adolescence: A 10-year study. Australian and New Zealand Journal of Psychiatry, 21, 36-43.

Biederman, J., Faraone, S., Mick, E., Wozniak, J., Chen. L., Ouellette, C., et al. (1996). Attention-deficit hyperactivity disorder and juvenile mania: An overlooked comorbidity? Journal of the American Academy of Child and Adolescent Psychiatry, 35, 997- 1008.

Bock, L. P. (1999). Differential diagnoses, co-morbidities, and complications of eating disorders. In R. Lemberg & L. Cohn (Eds.), Eating disorders: A reference sourcebook (pp. 41 -43). Phoenix, AZ:The Oryx Press.

Bowring, M. A., & Kovacs, M. (1992). Difficulties in diagnosing manic disorders among children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 611-614.

Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C, et al. (1993). Psychiatric risk factors for adolescent suicided case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 521 -529.

Carlson, G. A., Fennig, S., & Bromet, E. J. (1994).The confusion between bipolar disorder and schizophrenia in youth: Where does it stand in the 1990s? Journal of the American Academy of Child and Adolescent Psychiatry, 28, 221-228.

Faraone, S. V., Biederman, J., Wozniak, J., Mundy, E., Mennin, D., & O'Donnell, D. (1997). Is comorbidity with ADHD a marker for juvenile-onset mania? Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1046-1055.

Geller, B., Fox, L., & Clark, K. (1994). Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-year-old depressed children. Journal of the American Academy of Child and Adolescent Psychiatry, 33,461-468.

Geller, B., & Luby, J. (1997).Child and adolescent bipolar disorder: review of the past 10 yea rs. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1168-1176.

Geller, B., Williams, M., Zimmerman, B., Frazier, J., Beringer, L., & Warner, K. L. (1998). Prepubertal and early adolescent pibolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal of Affective Disorders, 51, 81 -91.

Greene, R. J. (1996). The explosive child. New York: Harper Collins.

Hazell, P. L., Carr., V., Lewin. T. J., & Sly, K. (2003). Manic symptoms in young males with ADHD predict functioning but not diagnosis after 6 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42\, 552-561.

Kovacs, M., & Pollock, M. (1995). Bipolar disorder and comorbid conduct disorder in childhood and adolescence. Journal of the American Academy of Child and Adolescence, 34, 715-723.

Lewinsohn, P. M., Klein, D. N., & Seely, J. R. (1995). Bipolar disorders in a community sample of older adolescents: Prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 454-463.

National Institute of Mental Health. (2000). Child and adolescent bipolar disorder: An update from the National Institute of Mental Health. Retrieved July 8,2004, from http://www.nimh.nih.gov/ publicat/bipolarupdate.cfm

Papolos, D. R, & Papolos, J. (1999). The bipolar child: The definitive and reassuring guide to childhood's most misunderstood disorder. New York: Broad way Books.

Popper, C. (1996). Diagnosing bipolar vs. ADHD: A pharmacological point of view. The Link, 13.

State, R. C., Altshuler, L. L., & Frye, M. A. (2002). Mania and attention deficit hyperactivity disorder in a prepubertal child: Diagnostic and treatment challenges. American Journal of Psychiatry, 159(6), 918-925.

Wozniak, J., Biederman, J., Kiely, K., Ablon, J. S., Faraone, S.V., Mundy, E., et al. (1995). Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 867-877.

Recommended Resource

The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorderhttp://www.bipolarchild.com

Angela D. Bard**k and Kerry B. Bernes are with the University of Lethbridge, Alberta, Canada. E-mail: abard**k@shaw.ca

SOURCE: American Counseling Association Oct 2005

Posted by Lindsay:

I am on a Children's Juvenile Bipolar Research Foundation Email list because my granddaughter who will be nine yrs old this Sunday may be bipolar. It is difficult to diagnose at an early age.
This was in my inbox and I thought someone may find it helpful. I know my daughter and I will be doing this online test with my granddaughter.





If this helps just one child it was well worth posting.

A HUGE thank you to Lindsay/Forum Admin for sharing the following excellent information!

Three Part Article - See the next 3 posts


Today, it's estimated that up to half a million children have bipolar illness, but the diagnosis remains controversial. A relatively small number of psychologists and psychiatrists treat the condition in young people. So how do parents, teachers, physicians recognize the brain disorder in a child, and then seek help?

by Karen Brown

What Is Bipolar Disorder in Children?
Part 1 of 3


Eleven-year-old Athena Rinaldo plays outside her Marlboro, Massachusetts home.
photo by Steve Schapiro

Eleven-year-old Athena Rinoldo beams as she does this practice cheer. As she jumps, her thin body practically ricochets off the walls of the mobile home she shares with her mother in Marlboro, Massachusetts. Her favorite teen idol is Hilary Duff, and she dreams of becoming a real cheerleader.

"We'll be doing round offs and cartwheels," explains Athena, "we'll be screaming our lungs out, and everybody's like, so happy they have me on their team because, like, I have so much energy."

Erin Redd**k is a 17-year-old rocker who lives in a Boston suburb.

"With my music, people tell me that I should write happy stuff, but that just doesn't work for me," says Erin. "The stuff that comes out of my mind is just like, you know, all sorts of negativity."

Fittingly, Erin's favorite color is black. She wears thick, dark eye-liner, tight jeans, and clunky silver pentacles around her neck. She's perfected a sarcastic stare, and when she wants to get away from her family, she writes songs in her basement studio.

"This one already has a name," she says as she starts a song. "It's called 'Go to Hell.'"

"This is Mr. Stick, he's like a stick figure," says Eric Rancke, a 16-year-old who likes to crack up his friends with his South Park-style cartoons. "In this one you see his building is burning, and then he runs by one person needing help, and then he runs by another person needing help. Until he gets to his room, and there's a beer sitting on a table, and he's like, 'Alright, it's still cold.'"

Eric usually wears baggy clothes and a backwards baseball cap as he lounges around his western Massachusetts home. He has visions of becoming a late night comedian, like his hero Conan O'Brien.

"Well, basically, one thing you should know," Eric explains, "I have no problem making a complete a** of myself."

You could easily picture these three kids at a comedy club, rock concert, or half-time show. But for Eric, Erin, and Athena, growing up has not gone according to plan. Athena was kicked out of her after-school cheerleading program for getting into fights. Erin has threatened her mother with a knife and was arrested for public drunkenness. Eric cursed out his middle-school principal and still holds the record for detentions. All three have been diagnosed with bipolar disorder.

"I think bipolar illness is hard for anyone at any age, but particularly if your brain hasn't developed, and hasn't been able to develop the kinds of friendships and relationships you need for support," says Dr. Kay Jamison, a professor of psychiatry at John's Hopkins University. In her book The Unquiet Mind, she writes about her own experiences with manic depression, which took hold when she was a teenager.

"You're at a time of life when everyone around you seems to be healthy," says Jamison, "and all of a sudden, you have an illness that affects your thinking, your energy, your ability to walk, talk, do all of the things that make you a human being. And so it's just a level of pain and suffering that I think is unimaginable unless you've actually been there."

"Just, there'd be times that I'd feel dead," says Erin, "or there'd be times when I'd feel on top of the world, but I wondered why I was so different from the other kids? Why I couldn't make friends, why I was the unpopular one, why I had decided to make myself dress different, listen to different music, why all this stuff was the way it was?"

But when does being different qualify as