Johnny is a 10-year-old boy whose parents brought him to my office because he is no longer responding to the stimulants that once helped so much. Increased dosage helped temporarily but his ill temper continued to break through. Now he is too strong to hold when he has tantrums. He has begun to hurt his younger brother and has threatened to hit his mother. Parents say that school is not such a problem, but crises at home are frequent, increasing and intolerable. Their son yells hateful epithets at them and has said that he would kill them or himself.
Case B
Mary, a 12-year-old girl who has been having difficulty paying attention at school, daydreams a lot and “can’t concentrate”. Her grades are C’s and D’s despite the intelligence to get A’s. Parents say she is well-behaved, well-liked, always in a good mood, talks excessively, has a difficult time waiting her turn, blurts out answers in school and is very distractible. She doesn’t get along with her younger sister. She has been on a number of different stimulants but they did not help her grades, poor organization, or inability to finish things that she starts. She feels quite badly about herself, but maintains high expectations. The family is intact with no major changes or difficulties.
Both youngsters had been diagnosed as having an Attention Deficit Hyperactivity Disorder (ADHD) and were treated with a combination of therapy, family work and medication. There was immediate improvement at times but an overall lack of improvement or worsening over time.
Bipolar Disorder or ADHD?
The disorder most commonly confused with Bipolar Disorder is ADHD. The two disorders can overlap but also have distinctions.
Yet mania also interferes with attention, increases irritability and impulsivity, and distractibility is essentially the same as a manic flight of ideas. It is not widely appreciated how similar these symptoms can be. Children with ADHD often experience secondary depression and yet depression is part and parcel of a Bipolar Disorder. It is not by accident that so many children with Bipolar Disorder have not been properly diagnosed.
Differentiation of the two disorders requires a careful medical psychiatric approach to diagnosis. The following areas are clinically useful to differential diagnosis and treatment:
Family History – A helpful distinction between the two disorders is a family history. Since both have a familial inheritance, a detailed family history looking for symptoms or diagnosis of either disorder among blood relatives can be useful. If Bipolar Disorder is revealed, the childhood history of those family members should be explored looking for similarities and differences. Many parents tell me that these possibilities were never considered.
School versus Home – If the behavioral difficulties are worse at home than in school, this may also lead to children with Bipolar Disorder, because they have the most difficulty under conditions of intense affect which is present in the most intimate relationships, (i.e., at home, a boy’s disappointment in his mother is much more intense than with his teacher or friends). At school, the focus is on work, not on feelings which are diffused over many different people, lowering the intensity of interactions.
With ADHD, the controlling variables are information overload and excitability. The child with ADHD often does very well in the home under low stimulation and poorly in school, despite being medicated,
Dissociate Symptoms – Children may feel as though they are outside their bodies watching themselves, may feel that they are not themselves or are fragmented. This may be a response to the intensity of manic emotions. Their drawings reflect this – often of robots or aliens rather than real people.
Other areas of importance in effective diagnosis include:
• Racing Thoughts
• Mood
• Energy and Aggression
• Grandiosity
• Egocentricity
• Hypersexuality
• Loss of Reality Testing
• Telling Tall Tales
• Resistance to Treatment for ADHD
In this era of managed care, it is also important that the child be properly diagnosed so that the appropriate level of services will be authorized. Medication, intensive personal and family therapy along with environmental interventions, special schooling, hospitalization and residential treatment all may be necessary for a child and his family to survive the ravages of this disorder. Parents need to understand this is a biologic, inherited disorder, that they are not at fault by their upbringing of the child, and that with proper treatment, their child can have a productive life.
Dr. Spivack is Director of COLUMBIA ASSOCIATES IN PSYCHIATRY, also known as <a href="http://www.pediapsych.com/">Pedia Psych</a>, the largest and oldest child and family psychiatric practice in the Washington Metropolitan Area with offices in Arlington, VA, Ashburn, VA, Crofton, MD and Kensignton, MD. Pedia Psych has special expertise in the area of <a href="http://www.pediapsych.com/ADHD.shtml">ADHD - Attention Deficit Hyperactive Disorder</a>. He is also Clinical Director of Child and Adolescent Programs at Dominion Hospital, Falls Church, VA.
