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Bipolar Disease and Attention Deficit Hyperactivity Disorder in childhood

By etavares On 30 September, 2010 Open Space | 2010 Comments Off on Bipolar Disease and Attention Deficit Hyperactivity Disorder in childhood No tags

Bipolar disease in children is more difficult to diagnose than in adults. It is a public health problem due to the severity and chronicity of the disease. The difficulty in diagnosing is related to the distinct manifestations of the disease during its early stages of development, whereas in adults it is associated to frequent comorbidity (Pavuluri et al., 2005). The dominant presence of bipolar disease in children is atypical, as the predominant signs are acute irritability, frequent chronic trajectory, and mixed symptoms of depression and mania.

It is important to evaluate comorbidity in children affected by bipolar disease, as it may imply anything from a diagnostic difficulty to a distinct therapeutic strategy requiring mixed treatment.

Sequels of comorbidity include increased prolongation of the disease, poorer diagnosis, and more resistance to treatment, which adds further costs to the disease.

The differential diagnosis versus comorbidity with Attention Deficit Hyperactivity Disorder (ADHD) is more complex, given that bipolar disease and ADHD have aspects in common with attention deficit, impulsiveness, motor hyperactivity and pressure to talk (Wozniak J, et al, 1995).
With the aim of shedding light on this issue, Faraone et al (1997) studied 140 children affected by ADHD. After stratifying the sample of ADHD children with and without bipolar disease, they noticed that, in both subgroups, there was a higher risk of ADHD among their relatives. However, only in children suffering from the two pathologies (ADHD and bipolar disease) the risk of bipolar disease in first-degree relatives was five times higher. This author suggests that comorbid attention deficit hyperactivity disorder with bipolar disease is familiarly distinct from other forms of ADHD, and may be related to pre-pubertal bipolar disease (Faraone et al (1997), Wozniak J, 1995).

Whether early or pre-pubertal bipolar disease is a distinct subtype of post-pubertal bipolar disease, or merely an earlier manifestation of the same disease, still needs to be ascertained (Weller EB, 2004). Given that early-onset bipolar disease presents distinct clinical and family risk aspects, some authors believe it is a subtype of bipolar disease.

When studying bipolar children and comparing them with hyperactive children, Geller pointed out that some symptoms that are characteristic of mania, such as elation, ideas of grandeur, reduced sleep, and sexual disinhibition were almost only noted in bipolar children. The symptoms found both on bipolar children and on children with ADHD were irritability, logorrhea, distractibility, and higher level of energy (Charfi, Cohen, 2005).

Hunt compared 3 groups of children ranging from 7 to 17 years of age. One of the groups presented irritability without elation, the other showed predominantly elation, and the third group was characterized by showing both (elation and irritability). He noticed that the group presenting irritability without elation was formed by children younger than in the other two groups, and that there were no other differences among the subgroups, namely in terms of severity of the disease, comorbidity, length of the disease, and family history of mania (Hunt et al, 2009). As the subgroup showing predominately irritability showed similar characteristics and similar family history of bipolar disease, like the subgroups presenting elation, we continue to consider episodic irritability in our diagnosis of paediatric bipolar disease.

In order to have a better understanding of the weight of irritability and hyperactivity in childhood bipolar disease, we will divide this pathology into restricted phenotype and extended phenotype. Restricted phenotype corresponds to children who totally fulfill the DSM-IV diagnosis criteria for hypomania or mania, including duration criteria and the presence of core symptoms of elevated mood and grandiosity. Extended phenotype corresponds to non-episodic chronic disease, which does not include core symptoms, but irritability, emotional lability, hyperactivity, impulsiveness, attention deficit, and aggressive choleric outbursts towards parents, peers and teachers (“affective storms”). This phenotype is core to this controversy, given that further research is necessary to ascertain if it really is a bipolar disorder that manifests itself during childhood, or if it refers to bipolar disorder prodrome symptoms pertaining to a distinct psychiatric disease presenting instability and mood changes. (Pavuluri et al.,2005).

The controversy about the relationship between bipolar disease and ADHD continues. Early-onset bipolar disease has a high percentage of comorbility, which requires

 

Paula Cristina Correia
Child and Adolescent Psychiatry Unit, Cova da Beira Hospital Centre
paula.correia@chcbeira.min-saude.pt

_______________________
Bibliography

1. Pavuluri MN, Birmaher B, Naylor MW: Pediatric Bipolar Disorder: A review of the past 10 years. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 2005, 44(9): 846-871.

2. Wozniak J, Biederman J, Mundy E, et al.: A pilot family study of childhood-onset mania. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 1995; 34:12: 1577-1583.

3. Faraone SV, Biederman J, Wozniak et al.: Is comorbidity with ADHD a marker for juvenile-onset mania? J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 1997, 36(8): 1046-1055.

4. Faraone SV, Biederman J, Mennin D, et al.: Attention-deficit hyperactivity disorder: a familial subtype? J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 1997, 36(10): 1378-1387.

5. Weller EB, Weller RA, Danielyan AK: Mood Disorders in Prepubertal Children. In: Wiener, JM, Dulcan MK. Textbook of child and adolescent Psychiatry. American Psychiatric Publishing, 3rd edition, 2004: 411-435.

6. Charfi F, Cohen D: Trouble hiperactif avec déficit de l’attention et trouble bipolaire sont-ils liés ? Neuropsychiatrie de l’enfance et de l’adolescence 53 (2005) 121-127.

7. Hunt J, Birmaher B, Leonard H, et al: Irritability without elation in a large bipolar youth sample : frequency and clinical description. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 2009, 48(7): 730-739.

8. Diler RS : Clinical Characteristics of bipolar disorder in children and adolescents. In : Figueira ML, Akiskal H. Clinical Aspects of Mania. Wolters Kluwer Health, 2009 : 63-81.

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Index - News # 16 | ago/set. 2010
 Editorial Note
 Cultural Soirée Commemorative of the 100th Anniversary of the Faculty of Medicine of the University
 Launch of the Electronic Staff Attendance Register at the Faculty of Medicine UL
 New members in the Editorial Team
 Molecular Medicine Institute (IMM) Researchers identify a new cell population of the immune system with therapeutic potential 
 Welcome II Programme
 FMUL welcomes new students
 Characterization – Psychiatry University Clinic from the Faculty of Medicine of Lisbon
 III Forum of Obesity Prevention Projects
 Medical Research in Portugal: Opportunities and Constraints
 Launching of the Book “”O meu amigo, o sono” (sleep, my friend)
 Book of the Month
 Master Degree in Diagnostic Technology and Cardiovascular Intervention – 2nd Edition
 Scientific Research Projects for Students
 Academic Examinations at the Faculty Of Medicine of The University Of Lisbon
 Publications FMUL/HSM/IMM
 Lecturers’ Participation in Academic Examinations Panels in other institutions
 Ongoing Training Courses at the Faculty of Medicine of the University of Lisbon
 Instituto de Medicina Molecular Seminars
 PhD Students 2010
 Consultation-Liaison Psychiatry and Bioethics
 Propensity towards Victimization: is it possible to diminish it?
 Exhibition of a Future Essay – Transformation, Creativity, and Art
 Parenthood in Multi-Problem Families
 Current Indications of Clinical Hypnosis
 The Issue on Rabdomyolisis
 Self-injury, self-mutilation, and self-aggression. The same definition?
 Day Hospital of the Psychiatry and Mental Health Unit of the Neuroscience Department of CHLN
 Bipolar Disease and Attention Deficit Hyperactivity Disorder in childhood
 Emotion and falling ill –Ongoing Research Projects
 Researching Science and Health
 Hospital, Scientific and Pedagogical Indicators of the Psychiatry and Mental Health Unity
 7th AstraZeneca Foundation / Faculty of Medicine of the University of Lisbon Research Grant
 Research: Instructions Handbook – 6 October
 European Depression Day (Portugal) October 2010
 JIMBA – Lower Alentejo Medical Internship Encounters – 8- 9 October 2010
 1st PAM (Porto’s Autoimmune Meeting) – 8 and 9 November
 Scientific and Technological Cooperation Competition – 15 October
 Cycle of Conferences on Health Technologies for Primary Health Care – 19 October 2010
 From Cardiac Insufficiency to Pulmonary Thromboembolism – 22 October
 28th Brazilian Congress in Psychiatry (CBP) – 27-30 October
 6th Psychiatry National Congress – 6-8 December 2010
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100 AnosPropriedade e Edição: Faculdade de Medicina da Universidade de Lisboa NIPC: 502662875  Periodicidade: Mensal  Diretor: Prof. Doutor Fausto J. Pinto Conselho Editorial: Prof. Doutor Fausto J. Pinto, Profª. Doutora Ana Sebastião, Prof. Doutor Mamede de Carvalho, Prof. Doutor António Vaz Carneiro, Prof. Doutor Miguel Castanho, Dr. Luís Pereira  Equipa Editorial:  Ana Raquel Moreira, Cristina Bastos, Isabel Varela, Joana Sousa, Maria de Lurdes Barata, Rui Gomes, Sónia Teixeira  Colaboração:  Gabinete de Relações Públicas, Internacionais e Comunicação  Versão Inglesa: AP|PORTUGAL- Language Services  Conceção: Metatexto, Lda. e-mail: news@medicina.ulisboa.pt  Sede do Editor e Sede da Redação: Avenida Prof. Egas Moniz, 1649-028 Lisboa Estatuto Editorial Anotado na ERC 

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