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Section 4
Differentiating Bipolar Disorder from ADHD

CEU Question 4 | CE Test | Table of Contents | Bipolar
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

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On the last track, we discussed three key aspects of suicide in bipolar children and adolescents: These were the rate of suicide; warning signs; and suicide triggers

As you know, many symptoms of bipolar disorder in children also match the criteria for ADHD, and often the two are confused.  Dr. Charles Popper has written extensively on the parallels between ADHD and mood disorders, and we will be using his criteria to help distinguish between the two.

On this track, we will examine three differences between ADHD and bipolar disorder. These three differences are rage, mood fluctuations, and other standard criteria.  Also, we will examine the possibility of comorbidity and the danger of misdiagnosis.

3 Differences between ADHD and BPD

1. Rage
The first criteria that Dr. Popper uses to distinguish between bipolar disorder and ADHD is the character of the client’s rage.  As we discussed on track 2, bipolar disorder children often exhibit unbridled tantrums.  This can be manifested in destructiveness  which is often an indication of ADHD. 

However, Dr. Popper points out that children with ADHD who are destructive do so out of carelessness while playing.  Those children with bipolar disorder destroy objects in a fit of rage and anger.  During such a tantrum, bipolar children often display disorganized thinking, language, and body position whereas ADHD children display none of these characteristics. Also, the duration and intensity of the tantrums differ in bipolar and ADHD children. While child clients with ADHD calm down after twenty to thirty minutes, a manic child will continue their destructive rage for up to four hours. 

Christopher, a seven-year old client of mine had been primarily diagnosed with ADHD and given a combination of medications.  However, his rage only intensified in the following weeks during which he threatened to throw a ten pound weight at his father’s head.  His mother received several bruises trying to restrain him.  As you can see, Christopher’s rage was a result of a manic episode, not ADHD. 

2. Mood Fluctuations
The second criteria that Dr. Popper suggests to distinguish between the two disorders is the mood fluctuations of the child client.  Although children with ADHD may exhibit extreme changes in mood, they do not exhibit depression as a predominant symptom.  Children with ADHD change moods quickly and are alert and ready in the morning upon waking.  Bipolar child clients, on the other hand, exhibit drowsiness and irritability upon waking. 

Triggers for mood changes also vary in ADHD and bipolar clients.  ADHD children are triggered by sensory and emotional overstimulation.  Bipolar children may be triggered by a simple parental "no". 

Also, if a child should ever demonstrate psychotic behavior, it is most likely that they suffer from bipolar disorder and not ADHD.  Christopher had often lost touch with reality, which included talking to voices that were not in the room and similarly answering questions that had not been asked by any physical person.  I quickly came to the conclusion that Christopher was suffering from auditory hallucinations during psychosis.  This obviously led me to believe that the primary diagnosis of ADHD by his previous psychiatrist was in fact wrong. 

3. Other Criteria
In addition to a client’s rage and mood fluctuations, several other criteria exist to determine bipolar disorder from ADHD in a child client.  They include the following:

1. Disturbances during sleep.  Children with early onset bipolar disorder experience severe nightmares often with themes of explicit gore and bodily mutilation.  To review night terrors in bipolar disorder, replay track 2.
2. Giftedness.  Bipolar children often have a penchant in certain cognitive functions, especially verbal and artistic skills.
3. Risk-seeking behavior.  Bipolar disorder children seek out dangerous situations whereas children with ADHD take risks out of carelessness and obliviousness.
4. Early Hypersexuality.  Children with bipolar disorder tend to have a strong early sexual interest and behavior.
5. Lithium.  The mood stabilizing element lithium improves bipolar behavior in children while having little or no effect on ADHD symptoms.
Using the above criteria, I have found that, once the distinction is made, ADHD and bipolar disorder are much easier to diagnose.

Comorbidity and Misdiagnosis
Fourth, we shall discuss the possibility of comorbidity.  In a recent study done by Dr. Janet Wozniak and Dr. Joseph Beiderman, it was documented that the parents and siblings of manic children not only had increased risk for mania and ADHD, but these two conditions occurred together in those same relatives.  This report indicates that co-occurring bipolar-ADHD is highly familial. 

However, many other researchers disagree with the comorbidity theory, instead pointing to a high percentage of misdiagnosis. Still, others claim that attention-deficit disorder with hyperactivity may be an early stage on a developmental path that concludes in full-blown bipolar disorder. Dr. Charles Popper states, "All of the features of ADHD can be seen in mood disorders at times, so ADHD is a diagnosis reached only after ruling out a mood disorder." 

There is a significant danger in diagnosing a child ADHD when he or she is in actuality bipolar.  This danger comes as a result of the very different medicinal treatment of the diseases. ADHD clients are treated with stimulants, which, given to a bipolar client, may instigate a manic episode, resulting in even more severe rages, as can be seen in the case of Christopher. 

On this track, we discussed three differences in ADHD and bipolar characteristics. These were rage, mood fluctuations, and other standard criteria.  Also, we examined the possibility of comorbidity and the danger of misdiagnosis.

On the next track, we will examine self-destructive behaviors commonly practiced by bipolar child clients, namely eating disorder; self-mutilation; and substance abuse.

Bipolar Disorder

- National Institute of Mental Health. (2008). Bipolar Disorder. U.S. Department of Heath and Human Services.

Peer-Reviewed Journal Article References:
East-Richard, C., R. -Mercier, A., Nadeau, D., & Cellard, C. (2020). Transdiagnostic neurocognitive deficits in psychiatry: A review of meta-analyses. Canadian Psychology/Psychologie canadienne, 61(3), 190–214.

Fortney, J. C., Pyne, J. M., Ward-Jones, S., Bennett, I. M., Diehl, J., Farris, K., Cerimele, J. M., & Curran, G. M. (2018). Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics. Families, Systems, & Health, 36(3), 267–280.

Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336.

Pendergast, L. L., Youngstrom, E. A., Merkitch, K. G., Moore, K. A., Black, C. L., Abramson, L. Y., & Alloy, L. B. (2014). Differentiating bipolar disorder from unipolar depression and ADHD: The utility of the General Behavior Inventory. Psychological Assessment, 26(1), 195–206. 

Soncin, S., Brien, D. C., Coe, B. C., Marin, A., & Munoz, D. P. (2016). Contrasting emotion processing and executive functioning in attention-deficit/hyperactivity disorder and bipolar disorder. Behavioral Neuroscience, 130(5), 531–543.

Online Continuing Education QUESTION 4
What are two major criteria in distinguishing early onset bipolar disorder from ADHD? To select and enter your answer go to CE Test


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