Through the story of a young teenager, this article explains how to determine whether your teen or patient struggles with bipolar disorder (BPD) and/or attention-deficit/hyperactivity disorder (ADHD). It also shows how a family is impacted by the unfolding of bipolar II disorder and discusses the symptoms of bipolar depression and hypomania as well as the difficulties in diagnosing bipolar conditions.
It was a challenging morning for 13-year-old Wade. He didn’t want to go to school and complained to his mother of fatigue. While Wade’s mother, Nancy, was concerned, she wondered if her son was secretly hoping for a day off to play computer games. His father, Doug, said the problem was all in Wade’s head and told him to go to school. One month later, Wade was still feeling fatigued and having difficulty concentrating at school. He would stare at a page, but somehow the content would not register. One teacher reported that Wade seemed to be going in circles because he wasted time and always seemed to be hunting for some misplaced item. He talked too much in class and would occasionally become defiant or swear under his breath when told to focus on his work. Two other teachers stated that his motivation was low and that he sometimes seemed distracted or inattentive. With dark circles developing under his eyes, Wade no longer looked forward to the day; just getting up in the morning was a major effort. He was more irritable than usual, snapping at his mother even if she simply asked how school went. He was also getting into more fights with his younger brother, Devon, and occasionally he refused to take a time-out. Wade also missed the attention of his father, whose work required long hours and regular travel.
A Visit to the Family Doctor
Nancy was growing tired of nagging Wade to do his chores, hearing his complaints, and dealing with his lack of motivation. She felt relieved when he was in school, but she felt guilty about these feelings. After several months of watching the growth of Wade’s problems, Nancy decided to take him to the family physician. Based on his symptoms, he was diagnosed with attention-deficit/hyperactivity disorder (ADHD), prescribed a stimulant, and told that he would most likely outgrow his condition. When Nancy spoke to her husband about the medication, he was strongly opposed and stated that his son couldn’t possibly need medication. The two argued about this issue for weeks until Doug acquiesced. While Nancy was hesitant to give her son a stimulant, she felt a sense of relief and hoped that Wade would get back on track. There are pros and cons to giving medication, and it is common for parents to disagree. Starting at a low dosage and monitoring your child or patient can help determine the dosage to take. In the majority of cases, young people need a mood stabilizer if they are diagnosed with bipolar II, but a percentage of kids can progress with good coping tools and psychotherapy.
The medication initially helped Wade. Now that he had more energy, doing daily chores became easier, and his grades improved. His concentration also improved and complaints of fatigue dwindled. He had the motivation to get up in the morning, and overall Wade did well for over a year. He seemed more like his old self, and the tension between Nancy and Doug decreased. They were able to enjoy family vacations, and Wade interacted more positively with Devon; however, the medication was only masking a more serious problem.
Overdiagnosis and the Side Effects of ADHD Medications
Many clinicians have expressed concern that ADHD is overdiagnosed; disorders that can be mistaken for ADHD include sleep apnea, hearing impairment, post-traumatic stress disorder, generalized anxiety disorder, bipolar disorder, and speech-language delays. ADHD is believed to have a neurological basis, and its symptoms are distractability, poor concentration, inattention, impulsivity and excessive energy. It is noteworthy that some researchers and medical professionals are concerned about the side effects of the stimulants typically used to treat ADHD. Stimulants can increase blood pressure, heart rate and body temperature, and they can decrease sleep and appetite, which can lead to malnutrition.
Barbara Geller, M.D., a professor of child psychiatry at Washington University School of Medicine in St. Louis, Missouri, states that “we want to distinguish between children with bipolar disorder and ADD because many parents, teachers and healthcare providers might confuse the overlapping symptoms of the two problems and think that these are just hyperactive kids.” Missing the bipolar II disorder in teenagers can cause young people much unnecessary suffering and lead to chronic depression, a decline in functioning, low self-esteem and rejection by friends. There are many symptoms of ADHD, and it’s important to remember that children are often diagnosed with the disorder when they are around 7 years old, and they may often do some the following:
- lose things necessary for tasks or activities at school or at home
- frequently do not listen to what is being said to them
- talk excessively
- shift from one uncompleted activity to another
- fidget with hands or feet or squirm in seat (adolescents may primarily experience restlessness)
- be distracted by extraneous stimuli
- have problems waiting turns in various types of games
- have difficulty sustaining attention in tasks or play activities
- have difficulty following through on requests from others
While we are moving toward being able to detect various mental health conditions with brain-scan imaging, currently most professionals prefer to rely on a thorough assessment. In many cases, busy doctors do not have the time to do a complete assessment, and a growing number of children are being inaccurately diagnosed. Although his parents did not know it yet, Wade did not have ADHD, he had bipolar II disorder.
Definitions and Symptoms of Bipolar I and II
Bipolar I disorder is characterized by episodes that alternate between manic periods (in which a person feels abnormally euphoric, optimistic, and energetic) and depressive periods (in which the individual feels sad, helpless, guilty and sometime suicidal). People with bipolar I can experience hallucinations and delusions while those with bipolar II do not.
Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. People with bipolar II depression have extremely low energy, slowed mental and physical processes, and profound fatigue. People with bipolar II struggle more with chronic depression while people with bipolar I struggle much more with mania. Wade had dysphoric mania, which is common among adolescents. It is mania characterized by anger and irritability that causes people to feel agitated a great deal of the time.
People with bipolar II can often function quite well because of their high energy levels, and generally they don’t have major impairment in their work, school or personal lives. However, other researchers indicate that bipolar II can be more serious due to the chronic and profound lows of the condition. We need more innovative treatment for bipolar depression because the lows can be profound fatigue, difficulty initiating tasks, difficulty getting things done, despair, hopelessness and thoughts of suicide. However, with the right combination of medication and solid coping tools, those people with severe depression can lead successful lives.
The symptoms of bipolar II include the following:
- anger, agitation, irritability, sometimes destruction of property
- racing thoughts, can’t stop thinking
- rapid speech, interrupting while others are speaking
- silliness, goofy behavior, acting like the class clown
- hypersexuality, high sex drive
- grandiosity (see definition below)
- staying up until 4 a.m., a reduced need for sleep
- intensely striving to complete goals
Keep in mind that hypomania has many faces and it is important to ask a variety of targeted questions to determine if your patient or teen is struggling with a cluster of bipolar symptoms. Generally, the depression of bipolar II has a more chronic course than bipolar I, but it does not have to if patients receive good treatment and commit to making changes. Positive coping skills, which are discussed later in this article, can help teens develop their ability to have successful lives in spite of the condition.
While ADHD and bipolar disorder have similarities, there are three symptoms that teens with bipolar disorder can have that ADHD kids do not have.
- Grandiosity – an exaggerated sense of one’s importance, knowledge, power or identity. The term is used to describe the larger-than-life feelings often experienced by people in a manic or hypomanic state.
- Abnormally elevated energy
- Hypersexuality – a high sex drive and/or an abnormally high interest in sex
Grandiosity surfaced in Wade’s bipolar as he moved into his middle teens. For example, when he scored four touchdowns in one season for his high school team, he thought he was going to play for the NFL. He was a good athlete at his school, but compared to players on other teams he was only average. Yet he persisted in believing he was NFL material. So, if you have a teen that has symptoms of ADHD but also seems to have one or more of the three symptoms listed above, it is very important to screen for bipolar disorder.
Differences between ADHD and Bipolar II Disorder
Bipolar disorder and ADHD are two separate conditions with overlapping symptoms that can make the correct diagnosis tricky. To further complicate things, a person can have both bipolar and ADHD, so do not just assume that it’s bipolar or ADHD but also consider that it could be bipolar and ADHD. Diagnosing ADHD and then prescribing certain medications can potentially make bipolar worse. Here are some general points to help you make this important diagnosis:
- Bipolar disorder is characterized by significant shifts in moods, but ADHD is characterized by hyperactivity, attention problems and impulsiveness.
- Teens with ADHD may feel sad periodically, but teens with bipolar II disorder can feel sad and depressed for long periods of time.
- Both ADHD and bipolar disorder patients experience anger, but it is manifested differently. Bipolar disorder can be marked by episodes of irritability, rage attacks and explosive anger. The person typically has a hard time settling down, can remain angry for hours at time, and can get tagged as having conduct or oppositional disorder. The ADHD teen’s anger generally comes from frustration and overstimulation, but ADHD anger will generally subside in about 15 to 30 minutes.
- Bipolar disorder in teenagers causes inattention because the teen is too depressed or excited to focus. ADHD causes inattention because the youngster’s brain is unable to focus for any length of time.
Always keep in mind that a teen can have both an ADHD condition and a bipolar II condition. This is a common combination as is bipolar and anxiety.
The Progression of Bipolar Symptoms
When Wade was 16 years old, things took a turn for the worse when his dog, Skippy, died. No matter how bad things got, Wade could always get unconditional love from his pet, something he now missed deeply. Skippy had been part of the family since Wade was two years old, and even Doug and Nancy felt sad about his passing. They offered to get a new dog for Wade, but he refused and said that he only wanted Skippy. Mood disorders are often triggered by a major loss or some sort of environmental stressor such as marital discord in the family, the death of a loved one, or bullies at school. For Wade, the loss of his dog triggered an array of symptoms.
Shortly after Skippy died, Wade began to once again complain of fatigue and a lack of energy, which are signs of depression. He found it hard to keep out of trouble: he started getting more physically aggressive with Devon, and he tenaciously tried to manipulate his mother by feigning nausea and stomachaches so he could take a sick day. He did these things even more when his father was gone on business trips. Wade became especially irritable when his parents praised his brother for good grades, and he denied cutting class when his parents found out about it. His grades were suffering because he wasn’t turning in assignments, and even his father noticed that Wade was becoming difficult to handle. Wade sometimes swore at his mother, and one day he punched his brother.
Wade’s parents took away his allowance to punish him, but this consequence seemed to have little effect on him – he continued with his unpredictable and aggressive behavior. The help that Nancy and Doug had hoped for in the medication didn’t come, and they again disagreed on how to handle the situation. Doug felt like Wade needed to quit the medication because it was not helping him anymore, but Nancy was concerned that his behavior might become worse without it. After several months of arguing and getting nowhere, Doug and Nancy were able to agree that a visit to Ms. Simmons, the school counselor, could help. Ms. Simmons was a specialist in relationship therapy and also in diagnosing depression. While Wade was initially resistant, he finally agreed to go. Deep down, Wade knew he needed some help. He knew that his parents had started relationship therapy and figured it might be what he needed. What Wade actually needed was talk therapy by a specialist in mood disorders who could teach him positive coping skills with a focus on improving his relationships. Using conversation as a tool, talk therapy is a general term that refers to many types of sessions held between a therapist (with expertise in the art of helping a patient psychologically) and a patient.
Meeting with the School Counselor
Ms. Simmons enjoyed working with teens and had a checklist of questions to determine if Wade might be struggling with a mood disorder. She had a lot of experience working with children and did not get derailed by kids with attitudes. Fortunately, Wade felt comfortable with Ms. Simmons and was happy that someone seemed to understand his side of things. Wade complained that his parents didn’t listen to him and that his father never gave him credit for the things he did well. As the interview progressed, Wade said that he felt like there was an engine inside of him, and that it was going too fast. He also told Ms. Simmons that his brain was too busy and that he couldn’t shut off his thoughts at night. Both of these are symptoms of bipolar disorder and typically do not exist in the ADHD population. Additionally, Wade shared that he had trouble concentrating and just didn’t understand what some of his teachers were talking about. Wade also admitted that he was jealous of Devon, who did well in school with little effort. Wade felt good talking with Ms. Simmons because she seemed to really understand what he was struggling with.
Based on some of Wade’s experiences, Ms. Simmons determined that he was struggling with some sort of depression. He periodically dealt with fatigue and would sometimes sleep for 15 hours straight. Sometimes he did not want to get up in the morning, but he would force himself to get going. When he felt depressed, he also had pessimistic thoughts. He would make distorted statements to himself such as “I’m just no good, and my parents only really love Devon.” This, of course, is a false and distorted statement and is common among people experiencing depression. As mentioned earlier, Wade also had problems with poor motivation. On some days he wasn’t interested in doing anything except listening to his music – his normal interest in life seemed to have vanished. Wade described that he felt stuck because his energy was jammed up, and he just couldn’t get moving forward. Many people with depression have trouble concentrating, and Wade felt like he was in a fog. It’s important to recognize that bipolar kids have trouble focusing due to the depression and hypomania, but ADHD kids have concentration problems because their brains cannot sustain attention.
Ms. Simmons was perplexed because Wade had such a range of symptoms. She could tell Wade was overwhelmed and seemed to be struggling with anxiety, concentration problems, aggression and excessive energy. She noticed how he kept tapping his feet and shifting around in his chair. She was also concerned with how rapidly Wade was talking and how he impulsively changed the subject occasionally. Having read that sometimes ADHD is confused with other disorders, Ms. Simmons wondered if Wade might be taking the wrong medication. Normally, a stimulant helps an ADHD child settle down and focus, but it was clear to her that Wade was still having trouble focusing, organizing his thoughts and relaxing. She met with both parents and recommended they have Wade see licensed psychologist Dr. Jones, a specialist in mood disorders. Fortunately, Doug had good health insurance through his job, and mental health services were covered.
Assessment by the Psychologist
A complete evaluation by a psychologist or psychiatrist is warranted whenever a child’s symptoms are interfering with relations at home, school or with peers. The assessment consisted of two interviews with Wade and two with his parents. After the assessments, Wade’s parents learned that he was probably grappling with an emerging bipolar disorder (BPD). Dr. Jones explained that BPD is a brain disorder that is strongly influenced by environmental stressors. Wade struggled with the following four stressors:
- The loss of his dog, who helped Wade settle down when he felt agitated or hyperactive.
- His parents’ arguments about him, which led him to believe that he was the cause of their unhappiness.
- A lack of support from his father, who was often away at work, and when he was home, he was somewhat harsh and rigid with Wade. Teenagers with bipolar disorder need fair and firm limits because a rigid approach agitates them more.
- Feeling stuck in a maze because he had great trouble moving out of a depressed condition.
Wade actually needed more support and understanding from his father, and this could have provided the self-soothing skills needed by teenagers with bipolar disorder. Teens with mental health conditions benefit greatly from the entire family understanding the conditions and working together as a team.
Bipolar – an Emerging Condition
Dr. Jones stated that the hyperactivity, impulsiveness and distractability so common to ADHD were symptoms of BPD as well. Doug and Nancy learned that BPD is a condition that often emerges over the adolescent years and may appear full blown in the early twenties. Dr. Jones advised them to be on the lookout for an increase in symptoms as Wade matured. If the symptoms increase, it is important to see (or revisit) a mood specialist for a medication assessment and family therapy. Retrospective studies indicate that adults with BPD often report that their symptoms started when they were adolescents, and fortunately, Wade was identified early on. It is especially important for parents to be forthcoming if there is a history of mental health challenges on either side of the family. Bipolar is largely a genetic condition, and parents need to recognize that they are not responsible for their genes.
Medication Therapy and Cognitive Behavioral Therapy
Many children and teens that actually have ADHD benefit from a stimulant medication, but a percentage of those diagnosed with ADHD actually have bipolar II disorder. Almost all people with bipolar I and II conditions need a mood stabilizer at some point in their treatment to counter the progression of the disorder. However, a percentage of those with bipolar II can get by with strong coping skills, good nutrition and sound sleep. When a teen has both bipolar disorder and ADHD, it is important to give the mood stabilizer first to prevent an episode of hypomania.
Cardiologists have expressed concern about the potential risks to the heart from long-term use of stimulants, and there is a growing trend of prescribing the lowest possible dose of these types of medications. Although the research is mixed, a percentage of experts believe the stimulant medication can trigger a manic episode if the teen is not taking a mood stabilizer.
Significant research also indicates that psychotherapy or cognitive behavioral therapy (CBT) combined with medication works best. CBT is a form of therapy that helps clients become aware of how they think in distorted ways and teaches them realistic and positive thinking patterns. This model has been very helpful in facilitating changes among people with mental health challenges.
Stimulants commonly used for ADHD include such medications as Ritalin, Adderall and Dexedrine. Some children are prescribed Strattera, which is not classified as a stimulant. These medications can be very helpful to teens with ADHD, especially when combined with some form of education and talk therapy. Research demonstrates that the major factor in treatment outcomes is how cared about the patient feels (I think that the same is true in the family). In other words, which technique is used is not as important as having a therapist with good skills who can make the patient feel cared about.
The Importance of Positive Coping Skills
Many children and teens can also be helped by developing positive coping skills for both bipolar disorder and ADHD. Parents who take the time to teach these skills can make a world of difference in the long-term success of their child. More information about helping those with ADHD can be found on the Internet, in libraries and bookstores, and in The ADHD Brain, a book written by Dr. John Amen, an expert in detecting and treating ADHD. Setting up the environment so teens can focus better with things such as having lists to complete after school and focusing on one thing at a time can make a significant difference. Forming routines is important and having a place for everything can help prevent the “going in circles” that is so common in teenagers with bipolar II and/or ADHD. Both groups can benefit from learning to relax, and this is especially true for bipolar patients when they have episodes of hypomania.
Targeted Questions for Your Teen
For some teenagers with bipolar disorder, the illness can start out with depression as it did with Wade. However, he also had subtle signs of the underlying hypomania which were confused with ADHD symptoms. In some cases, these subtle symptoms of hypomania are missed, and a major depression (or unipolar depression) is diagnosed instead. In other cases, signs of hypomania appear first, and it is important for parents and helping professionals to investigate to see if the young person has ever had depressed days. Since depression is a broad term, ask your child or patient some specific, easy-to-understand questions to find out about possible symptoms. The following are questions to help accurately diagnosis bipolar II disorder:
- Is it hard to wake up in the morning?
- Do you feel like you want to sleep a lot?
- Do you have trouble falling asleep, waking up a lot during the night, or staying up until all hours of the night?
- Do you have a hard time finishing tasks and other important things?
- Does it seem as if the day is gray? Do you feel down and depressed for part of the day or all day?
- Does it feel like your engine is going too fast?
- Do you feel like you’re not interested in anything?
- Have your grades gone down?
- Do you feel like it’s hard to get moving or that you sometimes feel like a banana slug?
- Do you have trouble focusing or concentrating on tasks?
- Do you ever feel like you have a high sex drive or can’t get your mind off sex?
- Has anyone ever mentioned that you talk too fast?
In essence, the goal is to figure out if your child or patient is having some symptoms of both the low states and the high states of bipolar. Remember there is overlap between the symptoms of ADHD and bipolar, and it is very important to differentiate between these two conditions. People with ADHD do not have grandiosity, elevated energy or hypersexuality, which are symptoms of bipolar.
Wade’s Diagnosis and Treatment
Wade had actually experienced both the lows and the highs of bipolar II, but some of his highs overlapped with ADHD, and because some of the more obvious signs of hypomania quickly gained the attention of the adults around him, he had been misdiagnosed with ADHD.
Fortunately, he was able to turn his interest in exercise into a major tool that helped him manage both his depression and his hypomania; running helped him with his depression, and tai chi helped him calm down and manage his hyperactivity. Getting small tasks completed from a master list helped Wade with both his depressive side and the highs of bipolar. He also benefited from therapy that was aimed at helping him to make realistic statements and to catch himself when he made distorted ones. His therapist helped him to understand his disorder and reassured him that he could attain the success he wanted as long as he practiced the positive coping skills and made them into habits. Wade had a lot of strengths, and because of his growing motivation, he was able to get on track toward a productive life. Remember there is hope, there is help and it can be just a phone call away.