RESPONSE TO THERAPY
Our group7 showed that pediatric manic and ADHD symptoms respond differently to mood-stabilizer treatment (Table 2).
We first used open-label divalproex sodium to treat manic symptoms in 40 children ages 6 to 17 with bipolar I or II disorder and concurrent ADHD. Serum valproic acid levels averaged 82 μg/mL. Manic symptoms improved in 80% of patients, whereas ADHD symptoms improved in <10%. Most children’s symptoms still met severity criteria for ADHD.
In a subsequent double-blind, crossover trial, we compared the effects of mixed amphetamine salts (MAS) or placebo on ADHD symptoms in 30 children whose manic symptoms stabilized on divalproex. MAS showed a significant, independent effect on ADHD symptoms One patient’s manic symptoms recurred during stimulant therapy and subsided with MAS discontinuation.
In this trial, mania symptoms responded to divalproex, whereas ADHD symptoms did not. MAS treatment showed a specific effect on ADHD symptoms of inattention, impulsivity, and hyperactivity. The shared symptoms of mania and ADHD (impulsivity and hyperactivity) decreased with divalproex to some extent.
Table 2
Pediatric mania and ADHD
respond differently to mood-stabilizer therapy
| Children with bipolar I or II disorder and concurrent ADHD | Treatment with divalproex, 8 weeks (N = 40)a | Subjects enter double-blind, crossover treatment with MAS and placebo, 2 weeks each (N = 30) | |
|---|---|---|---|
| Manic symptomsb | 32 of 40 (80%) improved; significant (P <0.0001) | MAS | Placebo |
| No significant change in manic symptoms (P = 0.17) | |||
| ADHD symptomsc | 3 of 40 (7.5%) improved; not significant (P = 0.96) | 26 of 30 (87%) improved | 3 of 30 (10%) improved |
| CGI scores improved 1.9 points more on MAS than on placebo, a significant difference (P <0.0001) | |||
| a Average divalproex blood levels = 82 μg/mL | |||
| b Manic symptom improvement defined as >50% decrease in baseline Young Mania Rating Scale scores | |||
| c ADHD symptom improvement defined as Clinical Global Impression (CGI)–Improvement scores of 1 or 2 | |||
| MAS: Mixed amphetamine salts | |||
| Source: Reference 7 | |||
WHEN MANIA/ADHD CO-OCCUR
ADHD and bipolar disorder symptoms overlap to a great extent, and the disorders can co-occur:
- Up to 20% of children diagnosed with ADHD also meet bipolar criteria.
- Two-thirds of children with bipolar disorder may also meet criteria for ADHD, with reports ranging from 29% to 98%.1,2
When trying to differentiate ADHD and bipolar disorder in children, consider the core symptoms of each diagnosis (Table 3).
Table 3
Core symptoms: Pediatric bipolar disorder vs ADHD
| Symptom | Bipolar disorder | ADHD |
|---|---|---|
| Euphoria/giddiness | Excessive | Appropriate to situations |
| Irritability | Severe and intense, often accompanied by tantrums | Occasional, may be caused by medication “wear-off” |
| Self-esteem | Grandiose | Demoralized |
| Sleep patterns | Decreased need for sleep | Difficulty settling at night |
| Speech patterns | Pressured, fragmented, with flight of ideas | Energetic and quick |
| Thought processes | Racing thoughts | Patients do not report racing thoughts |
| Psychosis can occur at times | ||
| Attention | Distractible | Distractible |
| Activity level | High energy, on-the-go, multiple projects, creative | Hyperactive, multiple projects |
| High-risk behaviors | Impulsive | |
| Disruptive behaviors | Can become aggressive | Intrusive and active |
Related resources
- Geller B, DelBello MP (eds). Bipolar disorder in childhood and early adolescence. New York: Guilford Press, 2003.
- Papolos DF, Papolos J. Bipolar child: The definitive and reassuring guide to childhood’s most misunderstood disorder. New York: Broadway Books, 2002.
- Fristad MA, Goldberg Arnold JS. Raising a moody child: How to cope with depression and bipolar disorder. New York: Guilford Press, 2003.
- Child and Adolescent Bipolar Foundation. Available at www.cabf.org. Accessed March 4, 2005.
Drug brand names
- Divalproex sodium • Depakote
- Mixed amphetamine salts • Adderall
Disclosures
Dr. Scheffer receives research support from and is a speaker for Abbott Laboratories.
Dr. Apps reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.