Bipolar Disorder-AD/HD Controversy
E. Watkins, M.D.
There is a great deal
of controversy about the diagnosis of Bipolar Disorder in Childhood.
Sometimes it can be difficult to differentiate AD/HD, irritable depression
and Bipolar Disorder in children.
Books such as The
Bipolar Child have received popular attention and raised public
consciousness about difficult to treat children with explosiveness and
rapid mood swings. While the book gives excellent descriptions of individual
children, it is not a research-based document. We have seen an increase in
the use of antipsychotics (such as risperidone and haloperidol )and mood
stabilizers (such as valproate and lithium) in younger children.
group at Harvard has published extensively about AD/HD and childhood Bipolar
Disorder. They feel that it can coexist with AD/HD and can often be reliably
diagnosed in childhood. Other researchers such as Peter Jensen (coordinator
of the MTA Study) and Gabrielle Carlson of NIMH are more cautious about
diagnosing childhood bipolar disorder. They feel that we do not yet have
enough evidence to show that children with rapid mood shifts or
explosiveness will grow up to have the same illness as adults with Bipolar
When Bipolar Disorder
starts in childhood, it tends to be more severe and the mood swings are more
rapid. At times the mania and the depression may even be mixed. The “up”
swings are often explosive or irritable. There may be fewer or no stable
moods between swings. We look for severe mood shifts, pressured speech,
episodic dangerously impulsive behavior, episodes of blind rage, thought
disorder, paranoia or hallucinations. We also look for a family history of
Bipolar Disorder or severe mood instability.
Given the uncertainty
among experts, how do we treat difficult children with inattention, mood
lability, explosiveness and rage? These children need a careful diagnostic
evaluation and close follow up. Even when things appear stable, it is not a
good idea to wait 4-6 months between clinical visits. Since these conditions
can evolve over time, repeated evaluations may be necessary. Remember that
medication response does not clinch a diagnosis. If we try to make a hard
and fast diagnosis of Bipolar Disorder too early, we may have a lot of false
positives. If a diagnosis of Bipolar Disorder becomes obvious when the child
is 15, it does not mean that the earlier evaluators missed an obvious
If a child or
adolescent does appear to have Bipolar Disorder co-existing with AD/HD, we
may use mood stabilizers, antipsychotics, benzodiazepines and other
medications. These medications can be a great help to certain children but
they do have potential side effects. The family and the entire treatment
team need to be involved in an overall plan. The use of stimulants in
children with both AD/HD and Bipolar Disorder is controversial. I use them,
but will first cover the individual with a mood stabilizer or an
antipsychotic. These children and adolescents are at particular risk for
substance abuse. It can be dangerous to combine illegal drugs with mood
stabilizers. Start drug abuse education early!!
County Psychiatric Associates
Our practice has experience in the treatment of Depression, Attention
Deficit Disorder (ADD or ADHD), Separation Anxiety Disorder, and other
psychiatric conditions. We are located in Northern Baltimore County and
serve the Baltimore County, Carroll County and Harford County areas in
Maryland. Since we are near the Pennsylvania border, we also serve the York
County area. Our services include psychotherapy,
psychiatric evaluations, medication management, and family therapy. We treat
children, adults, and the elderly. Visit our web site https://www.baltimorepsych.com
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Our practice has experience in the treatment of Attention
(ADD or ADHD), Depression, Separation Anxiety Disorder, Obsessive-Compulsive
Disorder, and other
psychiatric conditions. We are located in Northern Baltimore County and serve the
Baltimore County, Carroll County and Harford County areas in Maryland. Since we are near
the Pennsylvania border, we also serve the York County area. Our
services include psychotherapy, psychiatric evaluations, medication management, and
family therapy. We treat children, adults, and the elderly.
We also maintain a list of informative web sites on mental health
topics, such as Attention Deficit Disorder, Parenting and Support Groups.
Lutherville and Monkton
Baltimore County, Maryland
Web Site https://www.baltimorepsych.com
Postal address: We have two locations in Baltimore County
Monkton Office16829 York Road/PO
Box 544/Monkton, MD 21111
Lutherville Office: 2360 West
Joppa Road Suite 223/ Lutherville, MD
Email: [email protected]
Please use telephone for appointments or medical questions.
Carol Watkins, M.D.
Glenn Brynes, Ph.D., M.D.
Copyright © 2006 Northern County
October 04, 2007