Are comorbid ADHD and Bipolar Disorder a “double whammy?”

Attention Deficit Hyperactivity Disorder (ADHD) is a challenge. Bipolar Disorder is a challenge. When a child or teen has both, does the likelihood of mania double or worsen? Here’s the abstract of an interesting study that came out a few months ago in the journal Bipolar Disorder:

OBJECTIVE:
  To compare attention-deficit hyperactivity disorder (ADHD), bipolar spectrum disorders (BPSDs), and comorbidity in the Longitudinal Assessment of Manic Symptoms (LAMS) study.

METHODS:
  Children ages 6-12 were recruited at first visit to clinics associated with four universities. A BPSD diagnosis required that the patient exhibit episodes. Four hypotheses were tested:
(i) children with BPSD + ADHD would have a younger age of mood symptom onset than those with BPSD but no ADHD;
(ii) children with BPSD + ADHD would have more severe ADHD and BPSD symptoms than those with only one disorder;
(iii) global functioning would be more impaired in children with ADHD + BPSD than in children with either diagnosis alone; and
(iv) the ADHD + BPSD group would have more additional diagnoses.

RESULTS:
  Of 707 children, 421 had ADHD alone, 45 had BPSD alone, 117 had both ADHD and BPSD, and 124 had neither. Comorbidity (16.5%) was slightly less than expected by chance (17.5%). Age of mood symptom onset was not different between the BPSD + ADHD group and the BPSD-alone group. Symptom severity increased and global functioning decreased with comorbidity. Comorbidity with other disorders was highest for the ADHD + BPSD group, but higher for the ADHD-alone than the BPSD-alone group. Children with BPSD were four times as likely to be hospitalized (22%) as children with ADHD alone.

CONCLUSIONS:
  The high rate of BPSD in ADHD reported by some authors may be better explained as a high rate of both disorders in child outpatient settings rather than ADHD being a risk factor for BPSD. Co-occurrence of the two disorders is associated with poorer global functioning, greater symptom severity, and more additional comorbidity than for either single disorder.

So what does that mean? It means that if your child has both ADHD and Bipolar Disorder, yes, they are more at risk of having more severe symptoms of mania, they are more likely to have additional comorbid disorders, and their overall functioning is likely to be more impaired. That doesn’t mean they will be necessarily be severely impaired, however. It does mean, however, that your child is more likely to need treatment and that without it, they may be at significant risk of school problems and other problems.

Reference:
Arnold LE, Demeter C, Mount K, Frazier TW, Youngstrom EA, Fristad M, Birmaher B, Findling RL, Horwitz SM, Kowatch R, Axelson DA: Pediatric bipolar spectrum disorder and ADHD: comparison and comorbidity in the LAMS clinical sample. Bipolar Disorder, 2011, 13(5-6), 509-21.

Functional Brain Pathways Disrupted in Children with ADHD

New research presented at a Radiological Society of North America conference is offering new and important insight into ADHD.

Using functional magnetic resonance imaging (fMRI), researchers have identified abnormalities in the brains of children with Attention Deficit Hyperactivity Disorder (ADHD) that may serve as a biomarker (indicator) for the disorder.

ADHD is one of the most common childhood disorders, affecting an estimated five to eight percent of school-aged children. Symptoms, which may continue into adulthood, include inattention, hyperactivity and impulsivity behaviors that are out of the normal range for a child’s age and development.

According to the National Institute of Mental Health, there is no single test capable of diagnosing a child with the disorder. As a result, difficult children are often incorrectly labeled with ADHD while other children with the disorder remain undiagnosed.

“Diagnosing ADHD is very difficult because of its wide variety of behavioral symptoms,” said lead researcher Xiaobo Li, Ph.D., assistant professor of radiology at the Albert Einstein College of Medicine in New York. “Establishing a reliable imaging biomarker of ADHD would be a major contribution to the field.”

For the study, Dr. Li and colleagues performed fMRI on 18 typically developing children and 18 children diagnosed with ADHD (age range 9 to 15 years). While undergoing fMRI, the children engaged in a test of sustained attention in which they were shown a set of three numbers and then asked whether subsequent groups of numbers matched the original set. For each participant, fMRI produced a brain activation map that revealed which regions of the brain became activated while the child performed the task. The researchers then compared the brain activation maps of the two groups.

Compared to the normal control group, the children with ADHD showed abnormal functional activity in several regions of the brain involved in the processing of visual attention information. The researchers also found that communication among the brain regions within this visual attention-processing pathway was disrupted in the children with ADHD.

“What this tells us is that children with ADHD are using partially different functional brain pathways to process this information, which may be caused by impaired white matter pathways involved in visual attention information processing,” Dr. Li said.

Dr. Li said much of the research conducted on ADHD has focused on the impulsivity component of the disorder.

“Inattention is an equally important component of this disorder,” she said, “and our findings contribute to understanding the pathology of inattentiveness in ADHD.”

Shugao Xia, Ariane Kimball and Craig Branch, Ph.D. co-authored the report.

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Anxiety: an often-overlooked condition that may be present with ADHD

Trying to understand the impact of one condition can be a challenge, but some conditions tend to have a lot of other problems that “go with them.” ADHD is a disorder that has a tremendous amount of comorbidity. To help teachers understand that they need to be aware of “what else” the student with ADHD may have, I often use the following overhead:

Overwhelming, isn’t it?

With so much going on, it is somewhat understandable that teachers – and even parents – often overlook the presence of an anxiety disorder.  And yet anxiety may contribute to some of the worrisome behavior that they have been attributing to ADHD.   If a student becomes disruptive due to heightened levels of anxiety but their behavior is misunderstood as ADHD-related impulsivity or disinhibition, parents may think their child needs (more) medication for ADHD, when what they might really need is treatment for anxiety.  And increasing a stimulant medication to treat ADHD may make anxiety worse.

I came across an article online that may open some parents’ and teachers’ eyes about the relationship between ADHD and anxiety:

It’s not uncommon for individuals with attention deficit hyperactivity disorder (ADHD) to struggle with anxiety, whether it’s several symptoms or a full-blown disorder.

In fact, about 30 to 40 percent of people with ADHD have an anxiety disorder, which includes “obsessive-compulsive disorder, generalized anxiety disorder, phobias, social anxiety and panic disorder,” according to Roberto Olivardia, Ph.D, a clinical psychologist and clinical instructor at Harvard Medical School. The Anxiety Disorders Association of America even estimates the figure to be almost 50 percent.

Read more of this article on PsychCentral.

5-year-old with ADHD handcuffed, charged with battery on officer

All too often, I read something in the news that upsets me with all of my hats on – as a psychologist, a mother, and a disability rights advocate – like the item I posted earlier about using vinegar-soaked cotton balls in the mouths of autistic children or my coverage on this blog of the use of aversives and the  controversial Judge Rotenberg Center.  Other stories that are particularly upsetting to me are those involving the arrest of young children. I’ve posted some of those incidents in the past on this blog, and  in August, I read of another case where Toronto police handcuffed an autistic 9-year-old.  Then this week, I saw a news report from California by Dave Manoucheri of KCRA News involving a 5-year-old with ADHD that was very disturbing:

Earlier this year, a Stockton student was handcuffed with zip ties on his hands and feet, forced to go to the hospital for a psychiatric evaluation and was charged with battery on a police officer. That student was 5 years old.

Michael Davis is diagnosed with Attention Deficit Hyperactivity Disorder or ADHD. His mother says it has led to fights at school. But when the school district said it had a plan to change Michael’s behavior, his mother says things went wrong.

“Michael is energetic,” Thelma Gray said. “He is one big ball of energy.”

Gray calls Michael a comedian. She says his biggest problem is his ADHD stops him from thinking before he acts or speaks.

“He’s very loving,” Gray said. “He’s a good kid and he’s not the discipline problem that he was made out to be.”

Those discipline problems include fights with other students, even throwing a chair.

Gray says the school, Rio Calaveras Elementary of Stockton, wanted to change that behavior by having Michael meet with a school police officer.

“He could come out and talk to Michael and the kids are normally scared straight,” said Gray, describing how she says the school district proposed the meeting.

But the meeting didn’t go as planned.

You can read more of the news story on KCRA. In this case, the U.S. Department of Education reportedly did investigate and the news station obtained the report under Freedom of Information. I’m not sure why the department released the report and didn’t invoke FERPA like the district did, but the news station summarizes the report:

The report states that the Stockton Unified School District “delayed an evaluation of the student {Michael} which denied the student a fair and public education.”

They added that the school didn’t offer behavioral services to Michael or his mother, because “it would cost the district money.”

The report goes on to say that, whether or not funds are available through state or federal grants, the school district had an obligation to have Michael evaluated, which it failed to do.

The comments under the news story are also upsetting as the lack of understanding expressed by some people reminds me of how much ignorance still exists about ADHD.

But commenters aside, this case represents a total failure on the part of the school district, the building administration, and the state.

What the heck were the school personnel thinking if they thought a 5 year-old with ADHD could be “scared straight?” That they would even consider this approach demonstrates to me that they do not understand ADHD at all.

Would you want these people educating your child? I wouldn’t. This child might have (or may have?) been seriously psychologically harmed by their inappropriate handling.

I have often noted that schools fail to use research-validated or best practices in handling students with neurological challenges.  This is a case in point.  Have the school personnel received adequate training in how to educate students with ADHD (or other neurological disorders, for that matter)?  Are budgetary concerns an excuse for mishandling a student?

I am not a lawyer, but I hope that the family sues the district.  And I hope that as part of any settlement, the district is required to undergo training in best practices for educating students with neurological disorders – and is audited for compliance with I.D.E.A.

In various places around this country, parents have banded together to call for a halt to handcuffing young children. If you have not been involved in such advocacy efforts, you might want to look into what goes on in your area or state lest this happen to your child.

My kids are safe because they are out of school.  Are your children safe?

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UK study finds low rate of Bipolar Disorder in ADHD youth

One of the “hot” topics in recent years has been the comorbidity between ADHD and Bipolar Disorder – and how difficult some people find it to be clear about whether a child or adult has one, the other, or both.

When it comes to the rate of comorbidity (co-occurrence of the two disorders), results from studies have been all over the place, with one study suggesting that 94% of youth with Bipolar Disorder also have ADHD. Studies demonstrating high comorbidity rates of 80% or higher are not unusual, although there have been some studies – usually from non-U.S. samples – that find significantly lower rates. Hence, the range of estimates has been from 4% to 94%.

If you pose the question the other way, though, i.e., what percent of youth with ADHD also have Bipolar Disorder, studies report that 11-22% of ADHD youth also have Bipolar. In 2010, I visually summarized the results in a presentation this way:

If you have only been hearing about the high estimates, here’s more food for thought:

A study conducted in the U.K. of 200 youth with ADHD aged 6-18 years found that only one child, a 9-year-old boy, met diagnostic criteria for both ICD-10 hypomania and DSM-IV bipolar disorder not otherwise specified.

The study was published in the March 2011 issue of the British Journal of Psychiatry.

So… are we overdiagnosing Bipolar youth in the U.S. or is there some other explanation?

 

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