ADHD or Bipolar? Detecting Bipolar Among Lookalikes in Kids
Therapist George Lynn describes the fine differences between similar looking disorders in children: attention deficit / hyperactivity disorder (ADHD) and generalized anxiety disorder (GAD).
As a mental health counselor who works with children diagnosed with bipolar disorder and author of a book on the subject, parents often ask me to evaluate their elementary-school-age children for the presence of bipolar disorder. Not only are parents confused by some of the literature that describes bipolar disorder in children, they are also worried that their child is not getting the needed early intervention at home and at school, if indeed the child has bipolar.
In my evaluation, I distinguish bipolar disorder from two look-alike conditions, attention deficit/hyperactivity disorder (ADHD) and generalized anxiety disorder (GAD). I determine if the child fits into any of the three diagnostic categories. When the presence of bipolar disorder is identified, I ask myself if more than one condition may be present, secondary to the bipolar. Making my recommendation includes talking with the child, his/her parents, teachers, and other counselors, and identifying the presence of mood shifts, sudden rage, and a family component.
What is bipolar disorder?
The National Institute of Mental Health (NIMH) has identified the following characteristics of early onset bipolar disorder: depression, irritability, rage, poor frustration tolerance, mania, and psychosis and suicidal tendencies. All of these features are listed for bipolar disorder in adults in the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, except rage, psychosis, and poor frustration tolerance. The three criteria described below are based on research conducted at the U.S. National Institute of Mental Health and the clinical opinion of other researchers.
Mood shift: Children who have bipolar disorder typically experience dramatic shifts in mood ranging from calm to manic states to marked depressions. Also, children have more mood cycles of shorter duration than do adults. In order to be diagnosed with bipolar disorder, a child must experience mood shift from a “manic” or “hypomanic” mental state (a less intense mania) to a “depressed” state. Mania is best described as “mental overcharge,” or “mental over-excitation.” It may show as an “inappropriately elevated mood,” or simply as an extreme feeling of being mentally driven, unable to stop a rush of thoughts, emotions, or actions. “Hypomania” is the term used to describe a milder, non-disabling, form of mania.
Manic children believe that they can accomplish things magically. They may express this fantasy by jumping out of a moving car, climbing on the roof of a house and dancing, or thinking that they are powerful enough to throw a ball over a skyscraper.
Depression is a state of extreme sadness, lethargy, and physical debilitation. It is as much a physical syndrome as a mental condition. The child fatigues easily and experiences pain and increased vulnerability to stress; loses, or markedly gains, appetite; experiences the inability to sleep or the inability to stay awake; and may voice suicidal ideation.
Many parents assume their child is suffering from bipolar disorder because of severe depression, but to make the diagnosis of bipolar disorder, mania must also be present.
Sudden, explosive rage: The rage that occurs in bipolar disorder is different from anger. It happens at the drop of a hat with no provocation, and as Hagop Akiskal, MD, psychiatry professor and director of the International Mood Center at San Diego Veterans Administration Medical Center, and specialist on bipolar disorder in children, says, it is “sudden and explosive.” A raging child may attack others with weapons, may scream, cry, and laugh at the same time. The child is totally “beside himself” with misery.
The nerve centers responsible for rage are located in the limbic system or “animal brain” that contains structures essential to our survival through the “fight or flight” response. To the child in rage, it is a life and death struggle. As the limbic system flares on, adrenaline spikes, the child becomes stronger, and the thinking brain located in the frontal cortex shuts down.
Rage in children who have bipolar is closer to a seizure than an emotional event and is usually effectively treated with anti-seizure medication, the so-called “mood stabilizers.” The National Institute of Mental Health is carrying out research to determine if bipolar disorder and seizure disorders are directly related.
Family: Bipolar disorder has a genetic component. Research shows that if one parent is diagnosed with bipolar disorder, there is a significantly elevated chance that a child will meet diagnostic criteria for the disorder.
When doing an assessment for bipolar disorder in a child, I always query parents for information about the presence of bipolar disorder (also known as manic-depression) in the lives of the child’s mother, father, grandparents, aunts, or uncles. Because the exact diagnoses of immediate relatives may not be clear, part of my evaluation includes asking about psychiatric hospitalizations, suicides, depression, and alcoholism. Research shows a tight correlation between bipolar disorder and these factors. So if they are reported, I will look deeper into the issue to see if there is evidence of a mood disorder. If I do not detect bipolar disorder in a child’s family, I am very cautious about proceeding to the conclusion that the child fits the diagnosis.
What is ADHD?
When the following challenges are present in a child’s life, I make the diagnosis of attention deficit disorder with or without hyperactivity. The features listed here are tested on the Brown Scales, a popular clinical instrument for diagnosing attention disorders in children.
- Short-term memory problems that show up as low scores on the “digit span” test, which is part of the IQ test school districts use;
- Does not finish things and is very distractible;
- Has difficulty getting started on things that he/she does not find interesting;
- Does not pay attention when others are speaking to him/her and tends to daydream, and
- May show a chronically bad, irritable mood.
Some children with attention deficit disorders are also hyperactive. Unable to focus on anything in a satisfactory way, they are driven to move about in search of rewarding stimulation. They are very “motorically” restless and impish. Children with attention deficit disorders and without hyperactivity often say that they experience an internal hyperactive sense: “calm on the outside, a cyclone on the inside.”
Children with these issues may be delightful to be with because of their spontaneity, creativity, and high energy. Because they often have learning disabilities involving short-term memory and personal organization, school, and especially homework, may be torturous experiences for them.
What is GAD?
Generalized anxiety disorder is the diagnosis used to describe children who experience chronic dread that something bad is going to happen even though they cannot identify what it is. They worry all the time and do not like to take risks. They tend to be so hypersensitive to stimulation that they experience the world as continually irritating and continually threatening. They are chronically on edge. They have a difficult time separating from their mothers.
Certain words upset them. They may have germ obsessions. The air around them feels “electrified” with tension, as if people are living in a microwave oven. And they often have phobias, such as a fear of insects or of going out of the house.
Is it bipolar disorder or another condition?
Parents typically suspect their children “are bipolar” because their child is hyperactive, given to temper tantrums, and is very impulsive. Other characteristics include insomnia and oppositionality. In order to establish a diagnosis of bipolar disorder, I determine if these challenges express the criteria for bipolar disorder, or if the less severe diagnosis of ADHD or GAD is indicated.
Does hyperactivity express the mania of bipolar disorder or something else?
In bipolar disorder, hyperactivity is related to the inability of the child to regulate emotional energy in his/her brain’s limbic system—it is a form of hypomania.
In ADHD, hyperactivity is a cognitive issue and is caused by the child’s inability to hold focus on something long enough to take it in. The child is not pushed by his/her emotional brain, but is stuck in a random search pattern moving from one stimulus to another trying to gain focus and a sense of satisfaction from his/her experience.
In GAD, hyperactivity indicates that a child is “beside himself” with anxiety, feeling “out of his body and ten feet off the ground.” Though anxious children may be very distractible, they can be redirected. They need to learn how to slow down and breathe.
Do temper tantrums express bipolar disorder, ADHD, or GAD?
Children with bipolar disorder have rages, which are so intense that they cannot control themselves; children with ADHD and GAD have temper tantrums or meltdowns, the latter being when children are very angry and throw temper fits.
Children with ADHD and GAD generally experience meltdowns from frustration or high anxiety. They scream, cry, rant, throw themselves around, threaten, curse, and throw objects. However, you can talk to them and get through to them. They have some control over the reaction, as their “thinking brains” are still somewhat in charge. This is not the case in a bipolar rage where the child loses control. In fact, a child in the midst of a rage related to bipolar disorder does not respond to direction.
Does impulsivity express the hypomania of bipolar disorder or another condition?
Destructive impulsivity such as fire-starting and dangerous play is frequently correlated with bipolar disorder. Very young children who have bipolar may also demonstrate sexually inappropriate behavior years before they have any real interest in sex. This manifestation of impulsivity may involve touching parents or teachers sexually or making sexual remarks.
Impulsivity in children who have ADHD is caused by a failure of so-called “executive function,” the ability to make good decisions. Children with ADHD do impulsive things because, though they do care about consequences, in the moment, they are not thinking.
Children with GAD are not typically impulsive. They do experience panic, when they may run away mindlessly or strike out. This “impulsivity” expresses the “flight” aspect of the “fight or flight” reaction. Overwrought with taunting from classmates, the GAD child may throw over the desk and run out of the school building screaming threats all the way. Though this may look like impulsive behavior, it is rather what terrified children do when they believe they need to protect themselves.
Does oppositionality express bipolar disorder, ADHD, or GAD?
Here, I seek to find out if the child gives caregivers “moral authority” to govern his/her behavior—does the child accept their legitimacy to tell him/her what to do even though he/she does not want to do it? When their mood is cycling, children who have bipolar disorder act as though they do not care about the authority of parents and teachers and do not fear retribution for noncompliance.
Children with ADHD and GAD are oppositional because they are stuck emotionally as pre-schoolers at the “no-saying” stage. Because of genetics and a life-experience of failure, they do not feel a strong sense of who they are and therefore say “No!” to almost every demand put on them. But they do consider parents and other caregivers to have legitimate authority over them. Children with bipolar disorder typically see caregivers as “the enemy” when they attempt to assert their authority.
If anxiety is the cause of the oppositionality, children are not motivated by a desire to gain power over caregivers; rather they are motivated by a powerful anxiety related to their ineffectuality in the world. They feel like “nobodies” and lack the sense of “self-as-origin” necessary to proceed confidently and positively in life.
Does insomnia express bipolar disorder, ADHD, or GAD?
Children who have bipolar disorder experience severe disruption in their sleep-wake cycle, their circadian rhythms. Their brains wake up at night and become hyper-energized with thoughts that they must express. In the daytime, these children may be sleepy and depressed.
Children with ADHD experience insomnia because they cannot turn off their overcharged nervous systems. They report feeling unpleasantly buzzed, but they do not experience flight of ideas, or rapid verbal production. They simply can’t relax enough to drop into sleep or may sleep fitfully once they do drop off.
Children with GAD worry themselves awake. In bed, waiting for sleep, their minds have nothing to focus on and so begin to focus on all the things to worry or obsess about in their lives, giving them no rest.
I am careful in my analysis of these factors because I know that the wrong call on my part may mean that the right medication is not brought into the picture to help the child. The medications prescribed to treat an anxiety disorder or ADHD may destabilize a child challenged by bipolar disorder.
Another reason to take care is the impact of putting the label of “bipolar disorder” on how others view the child, and how the child sees him/herself. Researchers such as Daniel Siegel, MD, associate clinical professor of psychiatry at the UCLA School of Medicine and author of the award-winning The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are, point out that a key requirement for emotional development is that the child possesses a positive autobiography—a sense of self as worthy and powerful in the world. I try to “do no harm” in this regard.
If bipolar disorder is indicated, then what?
If I believe a child meets criteria for bipolar disorder, I immediately suggest that parents have the child evaluated by a psychiatrist with a specialty in the condition. A good way to find a doctor is to go to the Child and Adolescent Bipolar Foundation’s resources link online at www.bpkids.org. Another way is to log on to any local affiliates or parent support groups run by the NAMI organization (National Alliance for the Mentally Ill; www.nami.org). Once in contact with other NAMI parents, ask for their recommendations for physicians in your area.
It is also a good idea to have your child assessed for learning disabilities frequently seen with bipolar disorder, such as dyslexia, so that these can be taken into account when putting together the child’s program at school. Log on to the Web site of the Learning Disabilities Association (LDA) of America (www.ldanatl.org) to identify your local LDA chapter. To obtain a list of testing psychologists in your area, call your local chapter.
Correct, early diagnosis is key to success
The good news is that once identified as part of a child’s make-up, bipolar disorder is very treatable. Given appropriate medical treatment, people with bipolar disorder have the chance of living very successful lives. In fact, high intelligence, drive, and creativity are part and parcel of the condition. Early diagnosis gives parents a one up on the condition by linking them to support, education, and state-of-the-art medical management that will help them guide their children to splendid futures.
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George Lynn’s Book:
George Lynn’s new book, Genius! Nurturing the Spirit of the Wild, Odd, and Oppositional Child, will be available in bookstores in November 2005 (Jessica Kingsley Publishers). Learn how to implement seven key parenting strategies to bring out the best in children who have bipolar disorder and other neurological conditions. Advanced orders can be made at your favorite book retailer.
Genius! follows his popular parent and teacher guide: Survival Strategies for Parenting Children with Bipolar Disorder (Jessica Kingsley Publishers, 2000).
George Lynn is author of the groundbreaking guide, Survival Strategies for Parenting Your ADD Child (Underwood Books, 1996), for parents whose children have ADD with “extreme” behavior problems.
Printed as “Detecting bipolar among look-alikes”, Fall 2005