Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) are neurodevelopmental disorders with onset in childhood and early adolescence, and common persistence in adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed, leading to high rates of morbidity and disability. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history course of illness, and response to treatment. We review recent relevant findings and highlight epidemiological, clinical, family history, course, and treatment-response differences that can aid the differential diagnosis of these conditions in an outpatient pediatric setting.
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Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49:980–9. Epidemiology of adolescents mental health in the US, with prevalence and mean age of onset for the most common youth mental health issues.
Evans-Lacko SE, Zeber JE, Gonzalez JM, Olvera RL. Medical comorbidity among youth diagnosed with bipolar disorder in the United States. J Clin Psychiatry. 2009;70(10):1461–6.
Hodgkins P, Montejano L, Sasané R, Huse D. Cost of illness and comorbidities in adults diagnosed with attention-deficit/hyperactivity disorder: a retrospective analysis. Prim Care Companion CNS Disord. 2011;13(2):e1–e12.
Cherkasova M, Sulla EM, Dalena KL, Pondé MP, Hechtman L. Developmental course of attention deficit hyperactivity disorder and its predictors. J Can Acad Child Adolesc Psychiatry. 2013;22(1):47–54.
Frías Á, Palma C, Farriols N. Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment. J Affect Disord. 2015;174C:378–89.
Singh I. Beyond polemics: science and ethics of ADHD. Nat Rev Neurosci. 2008;9(12):957–64.
Feldman HM, Reiff MI. Clinical practice. Attention deficit-hyperactivity disorder in children and adolescents. N Engl J Med. 2014;370(9):838–46.
Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol. 2014;43(2):434–42.
Lee SI. Predictive validity of DSM-IV and ICD-10 criteria for ADHD and hyperkinetic disorder. J Child Psychol Psychiatry. 2008;49(1):70–8.
Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345–65. A meta-analysis of rates of mental illness in different countries, including differences in criteria used, training of clinicians, instruments used for the diagnoses.
Garfield LD, Brown DS, Allaire BT, Ross RE, Nicol GE, et al. Psychotropic drug use among preschool children in the Medicaid program from 36 states. Am J Public Health. 2015;105(3):524–9.
Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64(9):1032–9.
Jensen P, Hinshaw SP, Swanson JM, Greenhill LL, Conners CK, Arnold LE, et al. Findings from the NIMH Multi-modal Treatment Study (MTA): implications and applications for primary care providers. J Dev Behav Pediatr. 2001;22(1):60–73.
Biederman J, Mick E, Faraone SV, Spencer J, Wilens TE, Wozniak J. Pediatric mania: a developmental subtype of bipolar disorder? Biol Psychiatry. 2000;48(6):458–66.
Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA. 1998;279(14):1100–7.
Center for Disease Control and Prevention (CDC). Attention-deficit/hyperactivity disorder (ADHD). 2005. Available from: http://www.cdc.gov/ncbddd/adhd/.
Baroni A, Castellanos FX. Neuroanatomic and cognitive abnormalities in attention-deficit/hyperactivity disorder in the era of ‘high definition’ neuroimaging. Curr Opin Neurobiol. 2015;30:1–8.
Van Meter AR, Moreira AL, Youngstrom EA. Meta-analysis of epidemiologic studies of pediatric bipolar disorder. J Clin Psychiatry. 2011;72(9):1250–6.
Leverich GS, Post RM, Keck Jr PE, Altshuler LL, Frye MA, Kupka RW, et al. The poor prognosis of childhood-onset bipolar disorder. J Pediatr. 2007;150(5):485–90.
Perlis RH, Dennehy EB, Miklowitz DJ, Delbello MP, Ostacher M, Calabrese JR, et al. Retrospective age at onset of bipolar disorder and outcome during two-year follow-up: results from the STEP-BD study. Bipolar Disord. 2009;11(4):391–400.
Birmaher B, Axelson D, Goldstein B, Strober M, Gill MK, Hunt J, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study. Am J Psychiatry. 2009;166(7):795–804. Clinical features of bipolar disorder in youths during prospective follow-up of four-years. Some cases of BP-NOS progress to BP-I or –II, while others remain BP-NOS, or fail to persist.
Axelson DA, Birmaher B, Strober MA, Goldstein BI, Ha W, Gill MK, et al. Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified. J Am Acad Child Adolesc Psychiatry. 2011;50(10):1001–16.
Safer DJ, Rajakannan T, Burcu M, Zito JM. Trends in subthreshold psychiatric diagnoses for youth in community treatment. JAMA Psychiatry. 2015;72(1):75–83.
Nierenberg AA, Miyahara S, Spencer T, Wisniewski SR, Otto MW, Simon N, et al. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry. 2005;57(11):1467–73.
Beesdo K, Höfler M, Leibenluft E, Lieb R, Bauer M, Pfennig A. Mood episodes and mood disorders: patterns of incidence and conversion in the first three decades of life. Bipolar Disord. 2009;11(6):637–49.
Klein RG, Mannuzza S, Olazagasti MA, Roizen E, Hutchison JA, Lashua EC, et al. Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Arch Gen Psychiatry. 2012;69(12):1295–303.
Chen MH, Su TP, Chen YS, Hsu JW, Huang KL, Chang WH, et al. Higher risk of developing mood disorders among adolescents with comorbidity of attention deficit hyperactivity disorder and disruptive behavior disorder: a nationwide prospective study. J Psychiatr Res. 2013;47(8):1019–23.
Jerrell JM, McIntyre RS, Park YM. Correlates of incident bipolar disorder in children and adolescents diagnosed with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2014;75(11):e1278–83. A rare prospective study of predictors of bipolar disorder among youths treated for ADHD, including clinical features and treatment response.
Koolwijk I, Stein DS, Chan E, Powell C, Driscoll K, Barbaresi WJ. “Complex” attention-deficit hyperactivity disorder, more norm than exception? Diagnoses and comorbidities in a developmental clinic. J Dev Behav Pediatr. 2014;35(9):591–7.
Sihvola E, Rose RJ, Dick DM, Korhonen T, Pulkkinen L, Raevuori A, et al. Prospective relationships of ADHD symptoms with developing substance use in a population-derived sample. Psychol Med. 2011;41(12):2615–23.
Dalsgaard S, Mortensen PB, Frydenberg M, Thomsen PH. ADHD, stimulant treatment in childhood and subsequent substance abuse in adulthood—a naturalistic long-term follow-up study. Addict Behav. 2014;39(1):325–8.
Mannuzza S, Klein RG, Truong NL, Moulton 3rd JL, Roizen ER, Howell KH, et al. Age of methylphenidate treatment initiation in children with ADHD and later substance abuse: prospective follow-up into adulthood. Am J Psychiatry. 2008;165(5):604–9.
Biederman J, Faraone S, Mick E, Wozniak J, Chen L, Ouellette C, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry. 1996;35(8):997–1008.
Biederman J, Faraone S, Milberger S, Guite J, Mick E, Chen L, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry. 1996;53(5):437–46.
Duffy A. The nature of the association between childhood ADHD and the development of bipolar disorder: a review of prospective high-risk studies. Am J Psychiatry. 2012;169(12):1247–55.
Geller B, Williams M, Zimerman B, Frazier J, Beringer L, Warner KL. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord. 1998;51(2):81–91.
Fergus EL, Miller RB, Luckenbaugh DA, Leverich GS, Findling RL, Speer AM, et al. Is there progression from irritability/dyscontrol to major depressive and manic symptoms? A retrospective community survey of parents of bipolar children. J Affect Disord. 2003;77(1):71–8.
Luckenbaugh DA, Findling RL, Leverich GS, Pizzarello SM, Post RM. Earliest symptoms discriminating juvenile-onset bipolar illness from ADHD. Bipolar Disord. 2009;11(4):441–51.
Faraone SV, Althoff RR, Hudziak JJ, Monuteaux M, Biederman J. The CBCL predicts DSM bipolar disorder in children: a receiver operating characteristic curve analysis. Bipolar Disord. 2005;7(6):518–24.
Uchida M, Faraone SV, Martelon M, Kenworthy T, Woodworth KY, Spencer TJ, et al. Further evidence that severe scores in the aggression/anxiety-depression/attention subscales of child behavior checklist (severe dysregulation profile) can screen for bipolar disorder symptomatology: a conditional probability analysis. J Affect Disord. 2014;165:81–6.
Diler RS, Birmaher B, Axelson D, Goldstein B, Gill M, Strober M, et al. The Child Behavior Checklist (CBCL) and the CBCL-bipolar phenotype are not useful in diagnosing pediatric bipolar disorder. J Child Adolesc Psychopharmacol. 2009;19(1):23–30.
Doerfler LA, Connor DF, Toscano Jr PF. Aggression, ADHD symptoms, and dysphoria in children and adolescents diagnosed with bipolar disorder and ADHD. J Affect Disord. 2011;131(1–3):312–9.
Etain B, Jamain S, Milhiet V, Lajnef M, Boudebesse C, Dumaine A, et al. Association between circadian genes, bipolar disorders and chronotypes. Chronobiol Int. 2014;31(7):807–14.
Teicher MH, Faedda GL, Baroni A, McGreenery CE, Hernandez M, Grant MC, et al. Actigraphy rest-activity disturbances discriminate pediatric Bipolar Disorder from attention Deficit Hyperactivity Disorder and typically-developing controls. Biol Psychiatry. 2013;73(1S):312.
Faedda GL, Baldessarini RJ, Suppes T, Tondo L, Becker I, Lipschitz DS. Pediatric-onset bipolar disorder: a neglected clinical and public health problem. Harv Rev Psychiatry. 1995;3(4):171–95.
Teicher MH. Actigraphy and motion analysis: new tools for psychiatry. Harv Rev Psychiatry. 1995;3(1):18–35.
Kowatch RA, Youngstrom EA, Danielyan A, Findling RL. Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disord. 2005;7(6):483–96.
Baroni A, Hernandez M, Grant MC, Faedda GL. Sleep disturbances in pediatric bipolar disorder: a comparison between bipolar I and bipolar NOS. Front Psychiatry. 2012;3:22.
Cortese S, Faraone SV, Konofal E, Lecendreux M. Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry. 2009;48(9):894–908.
Masi G, Mucci M, Pfanner C, Berloffa S, Magazù A, Perugi G. Developmental pathways for different subtypes of early-onset bipolarity in youths. J Clin Psychiatry. 2012;73(10):1335–41.
Faedda GL, Marangoni C, Serra G, Salvatore P, Sani G, Vasquez GH et al. Precursors of bipolar disorder: a systematic literature review of prospective studies. J Clin Psychiatry. 2015;76(5):614–24.
Goldstein TR, Ha W, Axelson DA, Goldstein BI, Liao F, Gill MK, et al. Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Arch Gen Psychiatry. 2012;69(11):1113–22.
Ljung T, Chen Q, Lichtenstein P, Larsson H. Common etiological factors of attention-deficit/hyperactivity disorder and suicidal behavior: a population-based study in Sweden. JAMA Psychiatry. 2014;71(8):958–64.
Ballester J, Goldstein T, Goldstein B, Obreja M, Axelson D, Monk K, et al. Is bipolar disorder specifically associated with aggression? Bipolar Disord. 2012;14(3):283–90.
Geller B, Zimerman B, Williams M, Delbello MP, Frazier J, Beringer L. Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality. J Child Adolesc Psychopharmacol. 2002;12(1):3–9.
Bohman H, Jonsson U, Päären A, von Knorring L, Olsson G, von Knorring AL. Prognostic significance of functional somatic symptoms in adolescence: a 15-year community-based follow-up study of adolescents with depression compared with healthy peers. BMC Psychiatry. 2012;12:90.
Wozniak J, Faraone SV, Martelon M, McKillop HN, Biederman J. Further evidence for robust familiality of pediatric bipolar I disorder: results from a very large controlled family study of pediatric bipolar I disorder and a meta-analysis. J Clin Psychiatry. 2012;73(10):1328–34.
Smoller JW, Finn CT. Family, twin, and adoption studies of bipolar disorder. Am J Med Genet C: Semin Med Genet. 2003;123C(1):48–58.
Song J, Bergen SE, Kuja-Halkola R, Larsson H, Landén M, Lichtenstein P. Bipolar disorder and its relation to major psychiatric disorders: a family-based study in the Swedish population. Bipolar Disord. 2015;17(2):184–93.
Bienvenu OJ, Davydow DS, Kendler KS. Psychiatric ‘diseases’ versus behavioral disorders and degree of genetic influence. Psychol Med. 2011;41(1):33–40.
Berman SM, Kuczenski R, McCracken JT, London ED. Potential adverse effects of amphetamine treatment on brain and behavior: a review. Mol Psychiatry. 2009;14(2):123–42.
Faraone SV, Biederman J, Wozniak J. Examining the comorbidity between attention deficit hyperactivity disorder and bipolar I disorder: a meta-analysis of family genetic studies. Am J Psychiatry. 2012;169(12):1256–66. A meta-analysis of familial transmission of comorbid ADHD and bipolar disorder, showing elevated risk for both conditions.
Coon ER, Quinonez RA, Moyer VA, Schroeder AR. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1013–23.
Arnold LE, Ganocy SJ, Mount K, Youngstrom EA, Frazier T, Fristad M, et al. Three-year latent class trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD. J Am Acad Child Adolesc Psychiatry. 2014;53(7):745–60.
Judd LL, Schettler PJ, Akiskal H, Coryell W, Fawcett J, Fiedorowicz JG, et al. Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes. J Affect Disord. 2012;138(3):440–8.
Kessler RC, Green JG, Adler LA, Barkley RA, Chatterji S, Faraone SV, et al. Structure and diagnosis of adult attention-deficit/hyperactivity disorder: analysis of expanded symptom criteria from the Adult ADHD Clinical Diagnostic Scale. Arch Gen Psychiatry. 2010;67(11):1168–78.
Lahey BB, Pelham WE, Loney J, Kipp H, Ehrhardt A, Lee SS, et al. Three-year predictive validity of DSM-IV attention deficit hyperactivity disorder in children diagnosed at 4–6 years of age. Am J Psychiatry. 2004;161(11):2014–20.
Ricaurte GA, Mechan AO, Yuan J, Hatzidimitriou G, Xie T, Mayne AH, et al. Amphetamine treatment similar to that used in the treatment of adult attention-deficit/ hyperactivity disorder damages dopaminergic nerve endings in the striatum of adult nonhuman primates. J Pharmacol Exp Ther. 2005;315(1):91.
Lakhan SE, Kirchgessner A. Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain Behav. 2012;2(5):661–77. A review of medication’ safety of stimulants in ADHD, potential for abuse, overdosing, contraband, withdrawal and effect on cognitive functions.
Weyandt LL, Oster DR, Marraccini ME, Gudmundsdottir BG, Munro BA, Zavras BM, et al. Pharmacological interventions for adolescents and adults with ADHD: stimulant and nonstimulant medications and misuse of prescription stimulants. Psychol Res Behav Manag. 2014;7:223–49.
Dols A, Sienaert P, van Gerven H, Schouws S, Stevens A, Kupka R, et al. The prevalence and management of side effects of lithium and anticonvulsants as mood stabilizers in bipolar disorder from a clinical perspective: a review. Int Clin Psychopharmacol. 2013;28(6):287–96.
Young SL, Taylor M, Lawrie SM. “First do no harm”. A systematic review of the prevalence and management of antipsychotic adverse effects. J Psychopharmacol. 2015;29(4):353–62.
Goldsmith M, Singh M, Chang K. Antidepressants and psychostimulants in pediatric populations: is there an association with mania? Paediatr Drugs. 2011;13(4):225–43.
Clavenna A, Bonati M. Safety of medicines used for ADHD in children: a review of published prospective clinical trials. Arch Dis Child. 2014;99(9):866–72.
Biederman J, Monuteaux MC, Mick E. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med. 2006;36(2):167–79.
Tillman R, Geller B. Controlled study of switching from attention deficit⁄ hyperactivity disorder to a prepubertal and early adolescent bipolar I disorder phenotype during 6-year prospective follow-up: rate, risk, and predictors. Dev Psychopathol. 2006;18(4):1037–53.
Pataki C, Carlson GA. The comorbidity of ADHD and bipolar disorder: any less confusion? Curr Psychiatry Rep. 2013;15(7):372.
Gaynes BN, Christian R, Saavedra LM, Wines R, Jonas DE, Viswanathan M, et al. Attention-deficit/hyperactivity disorder: identifying high priority future research needs. J Psychiatr Pract. 2014;20(2):104–17.
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Conflict of Interest
Ciro Marangoni and Lavinia De Chiara declare that they have no conflict of interest.
Gianni L. Faedda has received royalties for book: “Parenting a Bipolar Child”, New Harbinger Publishing, CA.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Bipolar Disorders
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Marangoni, C., De Chiara, L. & Faedda, G.L. Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions. Curr Psychiatry Rep 17, 67 (2015). https://doi.org/10.1007/s11920-015-0604-y
- Attention deficit-hyperactivity disorder
- Bipolar disorder
- Clinical features
- Differential diagnosis