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Behavior: Ask the experts


Distinguishing ADAH from mania--not so easy. Boy keeps women's clothing--what could it mean?



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Q How do I tell whether a child has attention deficit hyperactivity disorder (ADHD) or is, in fact, in the manic phase of bipolar disorder? Several of my young patients were given a diagnosis of ADHD and placed on a stimulant, only to have the diagnosis changed to bipolar disorder several years later. Can any screening tool help distinguish these conditions earlier in their course?

Kenneth N. Wyatt, MD
Hendersonville, Tenn.

A Experts disagree on how to differentiate bipolar disorder— especially in its manic phase—from ADHD. While a thorough psychiatric and behavioral history and a review of diagnostic criteria for both disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are helpful in making a diagnosis, follow-up is extremely important to determine whether the initial diagnosis was correct.

In most cases in which the diagnosis appears to shift over time, both disorders probably have been present. Many experts believe that a large number of children given the diagnosis of ADHD actually suffer bipolar disorder. On the other hand, many labeled as having bipolar disorder may actually have ADHD. A specific primary diagnosis (or a comorbid diagnosis) is difficult to make in a child—whether ADHD or mania—because many symptoms occur with either condition.

Several basic distinctions help clarify the diagnostic dilemma:

  • Parents usually describe symptoms of mania several years after the onset of symptoms of ADHD.

  • A child with bipolar disorder is at higher risk of other severe psychiatric problems, especially conduct disorder and nonimpulsive aggressive behavior, than a child with ADHD.

  • A child with comorbid ADHD and mania is likely to have other special needs, such as severe reading and learning problems, aggression, and poor reality testing.

  • Bipolar disorder may have a higher incidence among family members of a child with ADHD who also has symptoms of bipolar disorder.

A child with bipolar disorder usually has chronic mood symptoms and is irritable but not euphoric, as are older manic children and adolescents. In addition, impulsivity in a child who has only mania may not be as marked as it is in a child with ADHD. When considering a diagnosis of bipolar disorder, therefore, a child with temper outbursts should be distinguished from one who has persistent irritability because the latter is more likely a manifestation of mania.

Disturbances of thought such as racing thoughts, delusions, and grandiosity are rarely seen in ADHD alone (Pliszka SR, Carlson CL, Swanson JM: ADHD with Comorbid Disorders—Clinical Assessment and Management. New York and London, The Guilford Press, 1999). Hypersexuality may occur in bipolar disorder but is not seen in a child who has only ADHD. And be mindful that some of these symptoms may not be seen in the very young manic child until later in childhood.

Be careful about the differential diagnosis in these difficult cases, especially when the child is young and symptoms of ADHD are full-blown. In such instances, consultation with a child psychiatrist or behavioral pediatrician would be helpful. You may be looking only at the aggressive behavior of a young child who turns out to have any one of many disorders, including oppositional defiant and/or conduct disorder, especially if the behavior is episodic.

To sum up, symptoms change as children develop. Because ADHD and mania are critical diagnoses, you must acknowledge that it is possible to err in diagnosing either disorder in a young child. Keep in mind that ADHD and the manic phase of bipolar disorder do coexist.

Martin Baren, MD

DR. BAREN practices educational, behavioral, and developmental pediatrics in Orange, Calif.

[Editor's note: For an in-depth review by Dr. Baren of another aspect of ADHD, see "ADHD in adolescents: Will you know it when you see it?" in the April 2002 issue of Contemporary Pediatrics.]


Q The mother of a 12-year-old boy in my practice became concerned about her son when she found articles of female clothing hidden under his bed. When she asked the boy about it, he said he used the clothes to clean his room. The mother, who collects used clothing to send to an underprivileged country, has found other items, including underwear, skirts, and a dress, on several occasions.

The first time I asked him about the women's clothes, the boy denied that he had been wearing them. Eventually he admitted it but refused to give any explanation. Later, he said that wearing the clothes excited him.

At my suggestion, the child started seeing a psychologist. The psychologist reported that the boy seemed fairly naïve regarding sexuality and had a limited knowledge of sexual terms. Sessions sometimes included the mother or father, but most of the time the boy attended alone. After four months of weekly sessions, he refused to go anymore.

Should the parents try another therapist? Should they wait and see? A psychiatrist saw the child for a single session, near the end of his treatment with the psychologist, but the boy did not want to return there, either.

The family members appear to have good relationships with one another. The parents come from low socioeconomic conditions and have only a third grade education, but they support education for their son and his 5-year-old sister. As far as I know, the boy has not been sexually abused or exposed to any sexual situations.

Adela Johnson, MD
Mineola, N.Y.

A I discussed your question with two child psychologists and two behavioral pediatricians. Each concluded that, if the behavior continues, an effort should be made to find an acceptable child psychologist or child psychiatrist for this boy.

It is unclear from your account what diagnosis was reached by the psychologist who saw the child weekly for four months and what the psychiatrist concluded. The boy's stage of puberty also is not stated. His behavior might represent a transient period in his sexual development.

Some questions to consider: Might the boy have seen a movie or video in which there was a transvestite? Has he played "dress up" with friends or cousins? Is there any history of sexual exploration during play with friends when he was younger? Does he have learning disabilities?

Evaluation of this boy and the significance of his behavior should take all of the above into consideration. If the psychologist continued therapy for four months, it seems likely that the boy has a significant problem. He might be more willing to see a therapist if he is given some choice in selecting the person who will treat him.

Karen Olness, MD

DR. OLNESS is professor of pediatrics, family medicine, and international health, Case Western Reserve University School of Medicine, Cleveland.


Behavior: Ask the experts. Contemporary Pediatrics 2002;7:31.

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