Distinguishing ADHD and Bipolar Disorder

Child & Adolescent Psychology

Assessment & Evaluation

Both ADHD and BMD display genetic relationships, although BMD does not seem to run in families to the degree seen in ADHD. With the ADHD established early in Clara's life, the focus of this assessment is on the possibility of co-morbid bi-polar mood disorder (BMD) and depression. While most individuals experience their first episode of BMD around the age of 18 or after -- the mean for diagnosis is 26 years of age -- children do rarely develop BMD. Clara would experience her ADHD as a chronic, consistent impairment, while the BMD is episodic, alternating with periods of normal levels of moods. That said, it is important to recognize that ADHD is typically associated with emotional reactions to certain trigger events, and that the people with ADHD are often quite passionate. The occasion of happy events bring ebullient reactions; unhappy experiences evoke intense sadness. The stark differences between BMD and ADHD with respect for moodiness are the rapidity of mood shifts and the grounding of moods in reality. For BMD, the shifts in mood are generally not connected to life events and actual experiences, and the mood shifts may take hours or days to change. In people with ADHD, moods are normal -- in that they are pegged to life events and experiences -- but they are more intense than what people without ADHD may feel, and they may appear instantaneous to observers because they may be triggered by quickly shifting perceptions and reactions to actual life circumstances.

People with ADHD experience rapid and frequent shifts of mood, while people who present with BMD evidence mood shifts with durations possibly running to several weeks. It should be noted that the DSM-V definitions of bi-polar disorders now recognize sub-types that do not fit the classic gateway questions, say, for mood duration and permit more of the mixed type patterns across the diagnoses.

It is certainly possible that Clara has experienced sexual abuse, and there are several indicators that this is a reasonable consideration. Clara's mother apparently dated following her divorce and now has a new partner living in the home. Clara's provocative behavior suggests that she could have been signaling sexual invitations to young and older males, establishing conditions for date rape or consensual (by social, not legal standards) sex. That said, it is important to guard against any bias in this direction that evidences a cultural or racial basis. It is not possible to determine a propensity for sexual activity at this time. There is no evidence from which to make that determination; however, the matter should be explored in therapy in order to determine if posttraumatic stress disorder (PTSD) is relevant to the diagnosis. Given these considerations, my treatment plan is based on a diagnosis of co-morbid ADHD and BMD. The determination as to whether a diagnosis of depression is warranted can wait until the therapist has seen Clara for several weeks following interventions. This is said in light of background depression as a component of BMD, and the possibility that Clara's expression of thoughts of suicide indicates a sense of being overwhelmed by the symptoms of her co-morbid mood disorder and attention disorder.

Individual and Family Therapy Plan

Consideration is given to the independent but coordinated treatment of the two disorders. Hausmann, et al. (2007) suggest that treatment and management of bipolar disease focus on psychosocial interventions, and that patients, therapists, and family members are likely to all be involved. By and large, this therapist does not see psychopharmacological therapy alone as effective, and recommend instead that cognitive behavioral therapy (CBT), psychoeducation, family focused psychotherapy (FFT), and also, potentially, a modified form of interpersonal psychotherapy (PSRT) be used with the objective primarily one of prolonging the time to a relapse (Hausmann, et al., 2007). By and large, the literature suggests that it is more effective to focus on the prevention of manic episodes rather than attempting to prevent the depressive episodes (Hausmann, et al., 2007).