Education and Counseling for Individuals Affected by Oppositional Defiant Disorder and ADHD

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Am I delusional or insane for even considering this?

A new member of Online Parent Support writes:

"I've found your website out of sheer desperation (bet you've heard that a time or two). I'm the step parent of an 18 year old boy who has been diagnosed in the past six months as being bipolar. He is abusing alcohol (no drugs as far as I can tell) and most days he has no respect for authority of any kind. Curfews are non existent and he can't hold a job. He was recently kicked out of a private catholic school ...and attempted suicide in October by overdosing on his meds.

The dilemma, number one he lives with his mom ...and she is demanding that his father and I ...take him. He is taking his meds, but not going to the weekly counseling that was recommended. His mother doesn't enforce any rules because she is afraid of him (he's been known to knock holes in the walls with baseball bats but has never injured anyone). Number two, his father travels out of state most of the time and I would be the primary person responsible for him if he were to come live with us.

...Am I delusional or insane for even considering this? Is moving something that would send him off the deep end completely? I will tell you that his relationship with his father is strong and his father is the calming factor in his life, something he readily acknowledges."


Hi L.,
I can't give you a simple, short answer for this one. The diagnosis of bipolar disorder in youth is often quite difficult, because the symptoms typically do not follow the symptoms and course of adult bipolar disorder. There is symptom overlap with several other more common childhood disorders. Also, many of the bipolar symptoms may be viewed as "normal but more extreme" childhood behaviors and emotional reactions. Underdiagnosis of childhood bipolar disorder has been noted by researchers, as has been underdiagnosis of many of these children's parents who are also bipolar.
Bipolar disorder is a severe mental illness manifested by recurrent episodes of depression, mania, and/or mixed symptom states. The expression of these symptoms (extreme shifts in mood, activity level, and behavior) significantly interferes with the child's functioning in the important arenas of his/her life - home, school, and peer interactions. In contrast to adult patients, children and some adolescents show a much greater percentage of mixed symptoms, expressing both depressive and manic behaviors at the same time (agitated dysphoria) or rapidly fluctuating moods.
Children may be irritable and hopeless, but also show increased recklessness and agitated thoughts and behavior simultaneously. Children most commonly present with a mixed and dysphoric picture, characterized by frequent short periods of intense mood lability and irritability, rather than classic euphoria - a picture of periods of hypomania interspersed with periods of dysphoria.
Up to 80% of children and adolescents who have bipolar disorder show complex cycling patterns, characterized by brief manic periods lasting four or more hours. Clearly defined episodes are less common. Most commonly seen is a mixed affective state without clear changes in eating and sleeping. Bipolar disorder beginning in childhood or early adolescence may be a more severe illness than in older adolescent or adult onset disease. Early episodic mood and energy symptoms/behavior seem to be at the core of an emerging bipolar disorder over an average interval of 10 plus years, as found in a study by Egeland.
In late adolescents with bipolar disorder, the most common mistaken diagnoses are schizophrenia (in up to 50% of cases) and conduct disorder. Attention deficit hyperactivity disorder has been the main differential problem in prepubertal and early adolescent patients. This differential problem is due to the high prevalence of coexisting ADHD among childhood onset bipolar disorder patients and from the overlap of certain DSM4 criteria for mania and ADHD (hyperactivity, distractibility and impulsivity).
Geller's research has demonstrated that although irritability is one of the most frequent symptoms of mania/hypomania at all ages, it is of little help in the differential diagnosis of children because of its ubiquity across childhood diagnoses (mania, major depressive disorder, ADHD, autism, and oppositional defiant/conduct disorders). Only a small percentage of children with irritability will have mania. Co-occurring irritability and elation is very frequent in both child and adult bipolar disorder.
There has been much controversy over the differentiation of mania from ADHD. The response or lack of response to stimulants is not diagnostically helpful. Geller found that of symptoms used to try to differentiate youth with ADHD from those with bipolar disorder, elated mood and grandiosity were symptoms best able to distinguish between the two groups. With bipolar disorder, hyperactivity may be more episodic. However, ADHD may be an initial manifestation of mania and is often comorbid with mania in children. A longitudinal study showed 98% of manic youths to also have ADHD.
Twenty-two percent of youth with ADHD met the criteria for mania. Prepubertal onset bipolar disorder is a nonspecific chronic rapid cycling mixed manic state that may co-occur with ADHD and conduct disorder or have features of ADHD and /or conduct disorder as initial manifestations. There is evidence that the high rate of comorbidity of ADHD with bipolar disorder may be an age dependent child manifestation that will decrease with age. The onset of bipolar disorder in those patients with a history of ADHD is between 11 and 12 years of age, according to several studies.
A developmental age specific view should be assumed when considering bipolar disorder in children and early adolescents, as most youth do not present with adult-like onset - i.e. people who have been functioning well until the abrupt onset of marked mania, which is responsive to treatment, and is followed by well-being between episodes.
Clear cut episodes are much less common in youths. There has been a shift of thinking from a "classic adult presentation" to a developmentally defined bipolar variant syndrome when considering children and young adolescents. Key features of this variant include a characteristic presentation of chronic mixed mania or continuous rapid cycling, marked irritability as the main mood abnormality, extreme and prolonged tantrums ("affective storms") and the frequent comorbidity of ADHD.
Many children who develop bipolar disorder develop a depressive disorder first. Of youth with major depression, 20-30% go on to develop mania. Psychosis is uncommon in prepubertal major depressive disorder, but delusions are a predictor of switching to mania in adolescent major depressive disorder.
Depressive symptoms include persistent sad or irritable mood, loss of interest in activities once enjoyed, significant change in appetite or body weight, difficulty sleeping or oversleeping, physical agitation or slowing, loss of energy, feelings of worthlessness or inappropriate guilt, difficulty concentrating, and recurrent thoughts of death or suicide. Early onset depressive disorder is associated with up to three times greater risk of bipolar disorder compared to adults.
Manic symptoms include severe changes in mood (either extremely irritable or overly silly and elated); overly inflated self-esteem, grandiosity; increased energy; decreased need for sleep (the ability to go with very little sleep); increased talking- talks too much, too fast, and changes topics too quickly; cannot be interrupted (pressured speech); distractibility (attention moves constantly from one thing to the next); hypersexuality (increased sexual thoughts, feelings or behaviors; use of explicit sexual language), increased goal directed activity or physical agitation; and disregard of risk (excessive involvement in risky behaviors or activities).
Pediatric mania can be difficult to diagnose. The major complicating difficulties in the diagnosis of pediatric mania are its overlap with ADHD, aggression, and conduct disorder, its overlap with substance abuse disorders, its association with trauma and adversity, and its response to treatment, which is atypical by adult standards.
Mania in children is seldom characterized by euphoric mood: the most common mood disturbance is severe irritability with "affective storms" (prolonged and aggressive temper outbursts). This type of manic irritability is severe, persistent, and often violent. In between outbursts, these children are described as persistently irritable or angry. Manic children often have a decreased need for sleep - not insomnia but an ability to function well on less sleep than normal. These children frequently receive a diagnosis of conduct disorder. Aggressive symptoms may be the primary reason for the high rate of psychiatric hospitalizations in manic children. Mania is often an antecedent and is strongly associated with substance use disorders, as well as a high risk for cigarette smoking.
Studies of prepubertal onset mania report high rates of comorbidity with several disorders, including anxiety disorders, oppositional defiant disorder, and conduct disorder. Mania at any age is frequently comorbid with severe anxiety. An association between early onset bipolar disorder and comorbid substance dependence and alcohol abuse has been described in young adolescents. Kovacs and Pollack found that the presence of comorbid conduct disorder in manic youths heralded a more complicated course of the bipolar illness.
The co-occurrence of mania and pervasive developmental disorders has been reported in the last few years. Children and adolescents with bipolar disorder almost always have other psychiatric disorders.
The incidence of mania appears to increase at the onset of puberty. The prevalence of mania during late adolescence is estimated to approximate that in adulthood. The prevalence of mania in childhood may be increasing. Earlier onset of bipolar disorder in successive birth cohorts has been reported.
Geller found that children are incapable of many manifestations of bipolar symptoms described in adults. She reports that five behavioral symptoms of childhood/early adolescence (which she views as equivalents of adult manic behavior) aid in correctly diagnosing childhood bipolar disorder. These manic symptoms, which do overlap with ADHD, are elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality (in the absence of abuse or overstimulation). She found that these five symptoms provide the best discrimination of childhood/early adolescent bipolar patients from uncomplicated ADHD patients.
Irritability, hyperactivity, accelerated speech and distractibility are very frequent in both childhood/early adolescent bipolar disorder and ADHD and are not useful in differentiating between these two diagnoses. Geller also found, however, that children and early adolescents with bipolar disorder have high rates of comorbid ADHD. Mixed mania (simultaneous mania and depression) is highly prevalent in childhood bipolar disorder. Mixed mania has been associated with worse outcomes in adults with mania.
The highest rates of onset of bipolar disorder for both males and females have been reported to be between 15 and 19 years of age. In the United States, half of the cases of bipolar are identified before 20. In the U.S., it is estimated that one third of persons with bipolar disorder receive treatment.
Many children with bipolar disorder are described by their parents of having had a difficult temperament in infancy. Great caution should be used in making a diagnosis of bipolar disorder in a young child with no family history of a psychiatric illness because of the difficulties in the diagnosis of young children with this disorder.
Bullying may be a developmental age specific manifestation of grandiosity. (Children who bully behave as though the rules and the law does not apply to them, similar to grandiose behaviors in older people.) About one-third of children with major depressive disorder develop bipolar disorder. Children with bipolar disorder who have histories of major depression often experience the onset of major depression before the onset of mania. Delusions are very uncommon in prepubertal bipolar patients.
When bipolar disorder begins before or soon after puberty, it is often manifested by continuous rapid cycling irritable and mixed symptoms, which may co-occur with disruptive behavior disorders. The rate of ultradian rapid cycling (mood disturbances occurring within 24 hours) is about 75% in bipolar children/early adolescents, much greater than in adult bipolar patients.
The ultradian rapid cycling (mixed state) is one in which children switch in and out of depression, irritable mania with explosions and euphoric "silly" mania unpredictably throughout the day, almost every day, with very little time spent in a regular age appropriate mood state. Despite this sort of chronicity, these children also are characterized by mood reactivity, and therefore may not show the abnormal moods the same way in all settings. Mixed mania, rapid cycling, and a chronic remitting course of illness has been reported in over 70% of prepubertal children with bipolar disorder.
In adolescents hospitalized with depression, several predictors have been reported to increase the likelihood that a patient will develop bipolar disorder - symptoms of psychomotor retardation, psychotic features, pharmacologic hypomania, and a family history of bipolar disorder. Although there are limited data on predictors of bipolar disorder in children, Post found that children who exhibited a combination of three or more of the following five symptoms - short attention span, grandiosity, irritability, racing thoughts, and suicidal gestures - had an 80% chance or more of developing bipolar disorder.
Psychotic features are a sign of more severe forms of depression and bipolar disorder. In bipolar disorder in children, psychotic symptoms are usually grandiose delusions, but can be mood incongruent hallucinations and paranoid delusions.
When psychotic symptoms are present in children and adolescents with mania, they are often misdiagnosed with schizophrenia. Schizophrenia is more likely to have an insidious onset, with no rush of speech or ideas or the engaging quality of mania and less likely to have a family history of mania. Patients with psychotic features are less responsive to treatment for bipolar disorder and depression.
The frequency of both bipolar disorder and major depressive disorder is elevated among the parents and relatives of childhood onset cases. For both bipolar and major depression, nongenetic factors interact with inherited vulnerability to determine the disorder.
Identification of an affective disorder in a child predicts the occurrence of both affective disorders and alcoholism in extended families. Conversely, paternal alcoholism influences the risk of offspring affective disorder. Therefore, the clinician who is caring for a bipolar child must look closely for parental psychopathology and/or alcoholism, which should be addressed with appropriate referrals. The clinician needs to continuously update the family history of the bipolar patient, as usually the parents are still within the age range of risk of developing a mood disorder.
Mania in childhood is associated with greater familial loading for affective illnesses than adolescent bipolar disorder. The risk of bipolar disorder in children in families with a strong family history of bipolar illness is high - about 40% in those with an affected parent and 25% in those with an affected second degree relative. Currently, there is no biological marker for either the genes associated with the major affective disorders or for the disorders.
Children with mania do not appear to grow out of it. Compared to adults, adolescents with bipolar disorder have a more prolonged early course and are less responsive to treatment. Mixed and rapid cycling presentations, which are more common in early onset cases, have a far more pernicious course than those with purely manic episodes. Adolescents with bipolar disorder have higher rates of completed suicide compared to those with unipolar depression.
Suicide is more common in mixed than manic presentations and increases with the severity of depressive symptoms. Important predictors of suicide include: a major depressive episode, comorbid substance abuse, past suicide attempts, a family history of major depression, and treatment with tricyclic antidepressants. Among adolescents, once bipolar is present or about to be, the risk of suicide attempts and completion rises dramatically. Manic symptoms and rapid cycling often trigger the suicide behaviors. Comorbid substance abuse and the availability of weapons further increase the risk.
Symptoms of mania can result from a variety of medical conditions, including prescription drug use (steroids, antidepressants, stimulants), neurologic disorders (head trauma, multiple sclerosis, temporal lobe seizures), systemic disorders (hyperthyroidism, porphyria) and substances of abuse (amphetamines, cocaine).
Symptoms of mania must also be distinguished from typical childhood behavior, including bragging, reckless behavior, overactivity and imaginary play. Also, the hypersexuality associated with mania can mimic the self-stimulatory and sexual acting out behaviors associated with children who have been abused or have witnessed adult sexual behavior.
There is a risk of overdiagnosis of bipolar disorder in children with conduct disorder and ADHD. The Mania Rating Scale (Fristad, Weller and Weller) has acceptable validity and reliability and can distinguish between manic and hyperactive children.
Prepubertal mania may follow a chronic course, characterized by high rates of relapse, psychiatric hospitalizations, chronicity, and the need for several medications (polypharmacy). Bipolar disorder is generally thought to be less responsive to treatment in adolescents than adults. Although the primary treatment of bipolar disorder is pharmacotherapy, individual and family psychoeducation is essential.
A good treatment plan generally includes medication, psychotherapy for the child, multi-family psychoeducational groups for the child and family, peer support for parents, and accommodations at school. Comprehensive psychosocial treatment is essential in the long term clinical management of children diagnosed with prepubertal mania. There is currently no standardized psychosocial treatment for early onset bipolar disorder, although this is currently being studied.
The treatment of ADHD in early onset bipolar disorder is controversial. Concern has been expressed about the use of psychostimulants to treat ADHD in children with mania and these drugs' potential risk for triggering affective episodes in vulnerable children. Clinical experience to date, however, suggest that stimulants, in combination with one or more mood stabilizers, may be safe and effective in the treatment of children with mania complicated by ADHD, and may result in improvement of the ADHD.
The use of mood stabilizers and antipsychotics in children and adolescents with bipolar disorder has increased significantly over the past decade. It is common practice to have patients continue on medications for some time after remission.
Several classes of psychotropic drugs have mood stabilizing properties, including lithium, valproate, carbamazepine, atypical antipsychotics (risperidone, olanzapine), and antiepileptic drugs (oxcarbazepine , clozapine, quetiapine, ziprasidone and aripiprazole). Data from recent studies suggest that many children and adolescents with bipolar disorder may require treatment with both mood stabilizers and an atypical antipsychotic to achieve a full response.
The atypical antipsychotics appear to be the most effective medication in stabilizing symptoms of childhood mania. Selective serotonin re-uptake inhibitors can cause activation that can be confused with mania or ADHD in children with bipolar disorder. Because additional medication for ADHD and depression may activate mania, these medications must be used cautiously, watching for exacerbation of mood instability in these patients.
A combined pharmacotherapy approach is often necessary to address the complicated comorbid clinical presentation. Neither antidepressant drugs or stimulant medications, with or without the concomitant antimanic drugs, predict recovery or relapse in these patients. Bipolar patients with comorbid substance abuse tend to have a less favorable response to medication treatment, specifically a poor response to lithium, than those without comorbid substance abuse.
In some cases, a less demanding academic course may be necessary on a temporary basis for these patients. Be sure to read the page in the eBook on this ==> CLICK HERE to go to that page. Children and adolescents who have difficulty managing their frustration in school may need special arrangements so that they do not disrupt others (allowing them to have a personal space which they can retreat to when necessary or allowing them to run laps around the school when they feel emotionally overwhelmed).
Bipolar disorder is a chronic, not uncommon disorder, with onset often beginning in childhood. Recurrence is common. Early onset mood disorders are often associated with an increased risk of developing other psychiatric disorders, substance abuse, and suicide and with poor academic, work, and social functioning. Studies have shown that children and early adolescents with bipolar disorder have a relatively poor outcome, compared to patients with adult onset bipolar disorder.
Intact families with positive interaction styles and less family dysfunction are associated with better outcomes in these patients. Low maternal warmth significantly predicts relapse after recovery. Psychiatric disorders among parents not only predicts the development of this disorder, but is associated with poor prognosis. More frequent episodes, increased severity, (particularly suicidality and psychosis) and comorbid disorders are likely to lead to fewer recoveries, longer episodes, and increased rate of recurrence.
The course of bipolar disorder in children and adolescents is typically a relapsing recurring illness with a substantial morbidity. Rates of relapse are quite high. Early onset bipolar illness has been associated with greater familial loading than adult onset illness, poor treatment response, and frequent recurrence.
A U.S. self-help organization, The Child and Adolescent, has a website for parents, which offers helpful information to families raising children or teens with early onset bipolar disorder.
This may be more info than you needed, but I felt it important to err on the side of giving you too much than not enough so you can make an educated decision on this very important matter.
Keep me posted on any new developments. And good luck. This will be a tough road, and you will need a lot of outside support from as many different sources as possible.

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