Bipolar Disorder and ADHD in Children: Confusion and Comorbidity

Laura A. Stokowski, RN, MS


October 27, 2009

In This Article

Children With Mental Health Disorders

A nurse working the evening shift in the emergency department (ED) enters a bay to see her next patient, an 8-year-old with a possible arm fracture. At first, it appears that the child is sitting on his mother's lap, but then the nurse realizes that his mother is holding him tightly because he is squirming and struggling to get away from her. He is crying and whining unintelligibly, and his mother is whispering for him to keep still.

The nurse introduces herself and begins to take a history from the mother, Mrs. K, who looks exhausted. Mrs. K reports that her son, Troy, jumped off of the top bunk bed at home and she thinks he broke his arm. "I told him he was going to break his arm if he jumped. He never listens to me," she says, looking at Troy as she speaks.

The nurse asks Troy to climb up onto the gurney. His mother moves onto the stretcher herself, lifting her son up with her. "He has ADHD [attention-deficit/hyperactivity disorder]," she explains apologetically, as the nurse attempts to examine Troy's arm. He is twisting around to get away from her, and she is wondering how they will ever get an X-ray. "Is he often like this?" she asks.

Mrs. K begins to cry. "I don't know what to do anymore. We've had him on the medicine for almost 3 months, and he seems to be getting worse." Mrs. K tells the nurse that her son's ADHD "comes and goes." Troy will be playing relatively quietly one moment, and then, out of the blue, he will start running around, breaking things, and hitting his brother. "If he doesn't get his own way, he goes ballistic. The school calls me every day. He's always talking in class, or acting like a clown to get a laugh out of the other kids. Or he's throwing things on the floor or turning over his chair. We put him in private school, but that's not working either. They said they would give him a few more weeks."

"He's really smart, but he just can't control himself. We never know what he will do next. I'm going to have to home school him until he outgrows this, but I don't know how I will survive. He never sleeps, so we can't either, because we're afraid of what he will do. I took him back to the pediatrician's office and now they're saying he might have oppositional defiant disorder on top of the ADHD."

The nurse could simply nod sympathetically, take care of Troy's arm, and turn her attention to the next patient. But she remembers reading something recently about the overlap between ADHD and bipolar disorder in children, and she wonders if, because of his young age, Troy was diagnosed properly. She says, "It's just possible that there could be something else going on, besides the ADHD. If so, he might need a different type of medication, something that might really help him. Would you consider taking Troy to be evaluated by a psychiatric clinical nurse specialist we work with?"

Whether they work in hospitals, clinics, or schools, nurses in all healthcare settings regularly encounter patients, including children, with diagnosed and undiagnosed mental health disorders.[1] As many as 1 in 4 adults and 1 in 5 children may suffer from a mental health condition, and a substantial proportion of these individuals meet the criteria for multiple mental health problems.[2,3] The lines between these disorders are often blurry, particularly in children. Children with anxiety disorders may also have mood disorders, and children with conduct disorders may also suffer from depression. Substance abuse and learning disorders frequently coexist with other mental health diagnoses.

Bipolar disorder (BD) and ADHD are 2 mental health conditions with a high degree of comorbidity in children. Overlapping symptoms between these disorders can make it difficult to distinguish them clinically. To differentiate BD and ADHD as well as to recognize when they are both present, it is important to understand ADHD and BD first as discrete mental health conditions.


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