Rating scales Some researchers have used behavioral rating scales to differentiate between the overlapping symptoms of ADHD and JBPD. One group found that children with JBPD scored significantly higher on the parent and teacher versions of the CBCL on the nonspecific dimensions, such as hyperactivity, aggressiveness, and anxiety.30 Another compared six different diagnostic tools and found that the Parent Report Form of the CBCL, followed by the CBCL-Teacher Report Form and then the CBCL-Youth Self Report, were most accurate at distinguishing children with JBPD from those with ADHD.31 These studies were consistent with previous research on the CBCL.32
In addition to behavioral rating scales, the Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) is the most widely used semi-tructured diagnostic instrument for evaluating JBPD.31 The
WASH-U-KSADS has been beneficial in identifying specific symptoms unique to bipolar disorder, including
mania, grandiose delusions, suicidality, hypersexuality, and ultrarapid or ultradian cycling.30 The WASH-UKSADS is a semistructured interview administered by trained clinicians to both the parent and the child.30 Scale developers have demonstrated excellent interrater reliability for the measure.33
While most practitioners utilize interviews and behavioral rating scales as diagnostic tools, the validity and reliability of these instruments have been questioned since they were originally designed for adult populations and they are not developmentally sensitive, particularly with bipolar disorder.3 Further, some scales, such as the Young Mania Rating Scale, were developed for quantifying behaviors, not for diagnosing a disorder.3 Experts continue to disagree on the most effective and accurate assessment tools for ADHD and JBPD because there is no gold standard for diagnostic evaluation.34 Thus, it is advantageous for pediatric clinicians to collaborate with pediatric psychiatrists and psychologists who can contribute specialized expertise to these evaluations.35
Figure 1 displays a clinical scenario and the diagnostic steps that a primary care provider and psychologist or psychiatrist may utilize to diagnose ADHD and JBPD. It is important that providers administer and interpret tests/behavioral scales only if they have been trained in their use.
Treatment
Once a diagnosis is established, treatment should be initiated and closely monitored. The treatment of ADHD and JBPD and associated comorbidities is currently an area of limited research. The Child Psychiatric Workgroup on Bipolar Depression recently published treatment guidelines for children and adolescents with bipolar disorder.36 These include algorithms for acute-phase treatment based on clinical trials, case reports, and expert panel recommendations for the treatment of type 1 bipolar disorder with and without psychosis. Lithium was the only pharmacologic agent included in the algorithm whose use was substantiated by controlled trials in children. Agents in the algorithm whose use was substantiated by randomized, clinical trials in adults included lithium, divalproex, carbamazepine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and lamotrigine.
The guidelines also discuss the roles of psychotherapy and electroconvulsive therapy along with the treatment of comorbid psychiatric illness.36 Medications used in the treatment of ADHD in children and adolescents include CNS stimulants such as methylphenidate, atomoxetine, bupropion; central alpha2-adrenergic agonists such as clonidine; and to a lesser extent, tricyclic antidepressants.4
Conclusion
Although differentiating ADHD from JBPD is a clinical challenge, the following tips may be helpful:
• The family psychiatric history is crucial. Children with typical ADHD do not have family histories with elevated rates of bipolar disorder, while those with JBPD often have families with higher than normal rates of bipolar disorder.
• Mood swings, serious depression, and marked irritability that is punctuated by explosive temper outbursts (rage storms) with serious physical aggression or destructive behavior are not hallmarks of ADHD but do occur more often among those with JBPD, particularly males. While children with ADHD may be somewhat oppositional when confronted with work requests, they do not manifest rage attacks, physically assaultive behavior, or property destruction as a matter of course.
• Mania, significantly elevated mood, grandiosity, significant irrational disturbances in thinking, and hypersexuality (in teens) are characteristic of JBPD and are not common features of ADHD.
• Highly elevated ratings across all dimensions (internalizing and externalizing) of behavior rating scales are more typical of JBPD than of ADHD (where externalizing scales are those most often elevated).
• Excessive speech, distractibility, restless or hyperactive behavior, and poor impulse control are characteristic of both ADHD and JBPD and are not likely to be helpful in the differential diagnosis.
The appropriate management of children with ADHD and/or JBPD is an attainable clinical goal that should be pursued by all pediatric practitioners, including PAs. A multidisciplinary evaluation that includes a complete history and physical examination, clinical interviewing, use of behavioral rating scales, and psychiatric consultation will lead to accurate diagnosis and appropriate treatment in nearly all cases. JAAPA
Lloyd Taylor is Assistant Professor, Department of Psychology, The Citadel, Charleston, SC. Noelle Carlozzi is a postdoctoral fellow in the Department of Psychology at Indiana University, Bloomington. Beverly Fortson is Assistant Professor, Department of Psychology, University of South Carolina, Aiken. Reamer Bushardt is Program Director, Department of Clinical Services, College of Health Professions, Medical University of South Carolina, Charleston. David Askins is Professor and Chairman, Department of Clinical Services, Medical University of South Carolina. Russell Barkley is Research Professor, Department of Psychiatry, State University of New York Upstate Medical University, Syracuse.
REFERENCES
1. Post RM, Chang KD, Findling RL, et al. Prepubertal bipolar I disorder and bipolar disorder NOS are separable from ADHD. J Clin Psychiatry. 2004;65(7):898-902.
2. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
3. Carlson GA. Juvenile mania versus ADHD. J Am Acad Child Adolesc Psychiatry. 1999;38(4):353-354.
4. Barkley RA. Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment. 3rd ed. New York, NY: Guilford; 2005.
5. Giedd JN. Bipolar disorder and attention-deficit/hyperactivity disorder in children and adolescents. J Clin Psychiatry. 2000;61(suppl 9):S31-S34.
6. Barkley RA. International consensus statement on ADHD. Clin Child Fam Psychol Rev. 2002;5(2):89-111.
7. Kent L, Craddock N. Is there a relationship between attention deficit hyperactivity disorder and bipolar disorder? J Affect Disord. 2003;73(3):211-221.
8. Stein MT, Marx NR, Beard J Jr, et al. ADHD: The diagnostic process from different perspectives. J Dev Behav Pediatr. 2004;25(5 suppl):S54-S58.
9. Barkley RA, Biederman J. Toward a broader definition of the age-of-onset criterion for attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1997;36(9):1204-1210.
10. Barkley RA. Adolescents with attention-deficit/hyperactivity disorder: an overview of empirically based treatments. J Psychiatr Pract. 2004;10(1):39-56.
11. Biederman J. Resolved: mania is mistaken for ADHD in prepubertal children: debate forum. J Am Acad Child Adolesc Psychiatry. 1998;37(10):1091-1096.
12. Reichart CG, Nolen WA. Earlier onset of bipolar disorder in children by antidepressants or stimulants? An hypothesis. J Affect Disord. 2004;78(1):81-84.
13. Roberts N, Parker KC, Woogh C, et al. Bipolar disorder in ADHD children grown up. J Am Acad Child Adolesc Psychiatry. 2000;39(6):678-679.
14. Geller B, Williams B, Zimerman B, et al. Prepubertal and early adolescent bipolarity differentiate from ADHD by mania symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord. 1998;51(2):81-91.
15. Faraone SV, Beiderman J, Wozniak J, et al. Is co-morbidity with ADHD a marker for juvenile-onset mania? J Am Acad Child Adolesc Psychiatry. 1997;36(8):1046-1055.
16. Tillman R, Geller B, Bolhofner K, et al. Ages of onset and rates of syndromal and subsyndromal comorbid DSM-IV diagnoses in a prepubertal and early adolescent bipolar disorder phenotype. J Am Acad Child Adolesc Psychiatry. 2003;42(12): 1486-1493.
17. Hazell PL, Carr V, Lewin TJ, Sly K. Manic symptoms in young males with ADHD predict functioning but not diagnosis after 6 years. J Am Acad Child Adolesc Psychiatry. 2003;42(5):552-560.
18. Kim EY, Miklowitz DJ. Childhood mania, attention deficit hyperactivity disorder and conduct disorder: a critical review of diagnostic dilemmas. Bipolar Disord. 2002;4(4):215-225.
19. Waxmonsky J. Assessment and treatment of attention deficit hyperactivity disorder with comorbid psychiatric illness. Curr Opin Pediatr. 2003;15(5):476-482.
20. Geller B, Zimerman B, Williams M, et al. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar phenotype compared to attention-deficit hyperactive and normal controls. J Child Adolesc Psychopharmacol. 2002;12(1):11-25.
21. Geller B, Craney JL, Bolhofner K, et al. Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry. 2002;159(6):927-933.
22. Biederman J, Faraone S, Mick E, et al. Attention deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry. 1996;35(8):997-1008.
23. Strand J. Anticipating the profession's future. JAAPA. 2002;15(10):51-54.
24. Wolraich ML, Lambert EW, Bickman L, et al. Assessing the impact of parent and teacher agreement on diagnosing attention-deficit hyperactivity disorder. J Dev Behav Pediatr. 2004;25(1):41-47.
25. Mattison RE, Gadow KD, Sprafkin J, et al. A DSM-IV referenced teacher rating scale for use in clinical management. J Am Acad Child Adolesc Psychiatry. 2003;42(4): 442-449.
26. Upadhyaya HP, Fields MC, Gray KM. Mood disorder: bipolar disorder. 2006. Available at: http://www.emedicine.com/ped/opic240.htm. Accessed November 27, 2006.
27. Soreff S, McInness LA. Bipolar affective disorder. 2006. Available at: http://www.emedicine.com/med/topic229.htm. Accessed November 27, 2006.
28. National Institute of Mental Health. Attention deficit hyperactivity disorder. 2003. Available at: http://www.nimh.nih.gov/publicat/adhd.cfm#diag. Accessed November 27, 2006.
29. Collett BR, Ohan JL, Myers KM. Ten-year review of rating scales, V: scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003; 42(9):1015-1037.
30. Geller B, Warner K, Williams M, Zimerman B. Prepubertal and young adolescent bipolarity versus ADHD: assessment and validity using the WASH-U-KSADS, CBCL and TRF. J Affect Disord. 1998;51(2):93-100.
31. Youngstrom EA, Findling RL, Calabrese JR, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry. 2004;43(7):847-858.
32. Biederman J, Wozniak J, Kiely K, et al. CBCL clinical scales discriminate prepubertal children with structured interview-derived diagnosis of mania from those with ADHD. J Am Acad Child Adolesc Psychiatry. 1995;34(4):464-471.
33. Geller B, Zimerman B, Williams M, et al. Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. J Am Acad Child Adolesc Psychiatry. 2001;40(4): 450-455.
34. Weller EB, Calvert SM, Weller RA. Bipolar disorder in children and adolescents: diagnosis and treatment. Curr Opin Psychiatry. 2003;16(4):383-388.
35. Kraemer S. Soapbox: who needs a child and adolescent psychiatrist? Clin Child Psychol Psychiatry. 1999;4:121-127.
36. Kowatch RA, Fristad M, Birmaher B, et al. Treatment guidelines for children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2005; 44(3):213-235.