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.

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?

 

Join Me at an All-Day Workshop for Educators & Parents on December 5th

I’ll be conducting an all-day workshop for educators on Monday, December 5, 2011 at the Grappone Conference Center in Concord, New Hampshire. The event is sponsored by the University of New Hampshire Institute on Disability and is geared to regular and special education teachers, school psychologists and social workers, behavior specialists, occupational therapists, administrators, and parents.

Description:

Neurological disorders that emerge in childhood often have significant impact on students’ academic, behavioral, and social-emotional functioning. Participants will learn about the cardinal features of Tourette’s Syndrome, Obsessive-Compulsive Disorder, Attention Deficit Hyperactivity Disorder, Executive Dysfunction, Mood Disorders such as Depression and Bipolar Disorder, and the memory deficits, sensory issues and “storms” that sometimes accompany them. Strategies and assistive technology to accommodate symptom interference in activities such as handwriting, homework, math calculation, and written expression and big projects will be described. Pitfalls in behavioral interventions, and simple social skills and problem-solving interventions will also be identified.

For more information on the workshop and registration information, download the brochure or register online at www.iod.unh.edu.

Hope to see you there!

 

Majority of United States Adolescents with Severe Mental Disorders Have Never Received Treatment for Their Conditions

A recent study by Merikangas and colleagues published in the January 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) shows that only half of adolescents that are affected with severely impairing mental disorders ever receive treatment for these conditions.

The researchers found that approximately one third of adolescents with any mental disorder received services for their illness (36.2%). Disorder severity was significantly associated with an increased likelihood of receiving treatment, yet only half of adolescents who were identified as having severely impairing mental disorders had ever received mental health treatment for their symptoms.

In the article titled “Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A),” Dr. Merikangas and colleagues examined the rates of treatment for specific mental disorders in the NCS-A. The NCSA is a nationally representative, face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States.

The authors examined rates of treatment for DSM-IV disorders, and correlated the severity, number of disorders, and comorbidity in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Sociodemographic correlates were also evaluated.

Treatment rates were highest in those with attention-deficit/hyperactivity disorder (ADHD) (59.8%) and behavior disorders, such as oppositional defiant disorder (ODD) and conduct disorder (CD) (combined 45.4%). The picture is more discouraging for those adolescents with anxiety, eating, or substance use disorders for whom less than 20% received treatment.

Furthermore, the investigators found that Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment. In the article, Merikangas and colleagues comment, “marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.”

Read the full press release on JAACAP.

Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder

Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders, according to an NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010.

Background

Some parents who take their child to a mental health clinic for assessment report that the child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. Some researchers suggest that this is how mania—an important component of bipolar disorder—appears in children. How mania and bipolar disorder are defined in children is important because rapid mood swings and high energy are common among youth.

Furthermore, many experts believe that overdiagnosis and misdiagnosis of bipolar disorder in youth may play a role in the increasing numbers of children being diagnosed with and treated for bipolar disorder. In choosing proper treatment, it is important to know whether children with rapid mood swings and high energy have an early or mild form of bipolar disorder, or instead have a different mental disorder.

In the Longitudinal Assessment of Manic Symptoms (LAMS) study, Robert Findling, M.D., of Case Western Reserve University, and colleagues assessed 707 children, ages 6-12, who were referred for mental health treatment. Of the participants, 621 were rated as having rapid swings between emotions and high energy levels, described as “elevated symptoms of mania” (ESM-positive). Parents of the other 86 children did not report rapid mood swings. These participants were deemed ESM-negative.

Results of the Study

At baseline, all but 14 participants had at least one mental disorder, and many had two or more. Attention deficit hyperactivity disorder (ADHD) was the most frequent diagnosis, affecting roughly 76 percent in both the ESM-positive and ESM-negative groups. However, only 39 percent were receiving treatment with a stimulant, the most common medication treatment for ADHD, at the start of the study.

Only 11 percent of those with rapid mood swings and high energy (69 out of 621) and 6 percent of those without these symptoms (5 out of 86) had bipolar disorder, meaning that only this small percentage had ever experienced a manic episode, as defined by the current diagnostic system. Of the children with rapid mood swings and high energy, another 12 percent (75 children) had a form of bipolar disorder that includes much shorter manic episodes.

Compared to children without rapid mood swings and high energy, those with these symptoms:

• Reported more symptoms of depression, anxiety, manic symptoms, and symptoms of ADHD
• Had lower functioning at home, school, or with peers
• Were more likely to have a disruptive behavior disorder (oppositional defiant disorder and/or conduct disorder).

Significance

Given that 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder, the researchers suggest that bipolar disorder may not be common among children who experience rapid swings between emotions and high energy levels. Nevertheless, children with these symptoms experience significant impairments due to mood and behavior problems.

The researchers also noted that ESM-positive and ESM-negative youth were prescribed psychotropic medications—including antipsychotics—at similar rates. Further study may provide insight into how serious mental illnesses should be treated in children.

What’s Next

The study participants will be re-assessed every 6 months for up to 5 years, allowing the LAMS researchers to determine which children with rapid mood swings and high energy develop bipolar disorder later in life. Such research may inform efforts to identify early markers or predictors of the illness as well as possible protective factors.

Reference

Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold E, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM. Characteristics of Children With Elevated Symptoms of Mania: The Longitudinal Assessment of Manic Symptoms (LAMS) Study. J Clin Psychiatr. Epub 2010 Oct 5.

Source: NIMH

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