ADHD and bipolar disorder are both mental disorders that can cause problems with focus, energy, mood, and impulsivity. People with ADHD have difficulty paying attention, controlling impulsive behaviours, or being overly active. Those with bipolar disorder experience extreme changes in mood, energy, and behaviour.

ADHD is one of the most common mental disorders in children and adolescents. It is estimated that between 3 and 5% of school-aged children have ADHD. Bipolar disorder is less common, affecting about 1-1.8% of all children, but that’s still a lot of children! Until only quite recently it was believed that only adults could have bipolar. However, research has shown that approximately 65-70% of adults started seeing symptoms in their childhood or adolescence. One study showed that roughly 30% of adults with bipolar reported symptoms before the age of 13. This can also be termed early-onset bipolar or paediatric bipolar.

What is Bipolar Disorder?

Bipolar disorder is a mental illness that causes extreme mood swings. It was previously known as manic depression. The highs, or manic episodes, can last for days or even weeks. During these times, people with bipolar disorder may have more energy than usual and feel like they can do anything. They may also act impulsively and make poor decisions, like spending too much money or engaging in risky activities. The lows, or depressive episodes, can last for weeks or even months. During these times, people with bipolar disorder may have trouble getting out of bed, and they may feel hopeless and worthless.

For children the cycles between manic and depressive episodes can occur far more frequently, instead of over days, weeks or months, they can be all in one day.

What Causes Bipolar Disorder?

There is no single cause for bipolar disorder. Instead, it is thought to be caused by a combination of:

• Chemical factors – chemical imbalances in the brains neurotransmitters
• Extreme Stress – money, physical illness, relationships
• Traumatic Life Events – marriage breakdown, abuse, death of a loved one
• Drug and/or alcohol abuse
• Genetics – tends to run in families

Men and women from all backgrounds can develop bipolar disorder. Some people may only experience a couple of episodes in their lifetime whilst others may have more frequent occurrences. Generally bipolar will be seen in someone before the age of 40.

Signs and Symptoms of Bipolar in Children

The DSM-5, which is the diagnostic manual used to classify mental disorders in the US, and the ICD (International Statistical Classification of Diseases and Related Health Problems) which is written by the WHO (World Health Organisation) appear to lack signs and symptoms specifically in children and just focus on adults. I did have a look, but my word, you have to scroll lots and they use big words!

So, in layman’s terms, because I don’t need that stress in my life, I have broken down the signs and symptoms of bipolar into the manic side and the depressive side. Parents really need to watch out for these massive mood swings from mania to depression.

Mania symptoms in children

• Talking very fast and switching topics mid-sentence
• Quick meltdowns and violence over very small issues
• Hyper focusing on a thing or subject
• Acting hyper, overly happy or silly for no real reason which is unusual for them
• Erupting at the word ‘No’
• Sleep issues, not needing naps or rest; difficulty settling; up in the night
• Talking and thinking about sex and sexual things at inappropriate times
• Seeing or hearing things that aren’t there (psychosis)
• Very imaginative

Mania in children with bipolar can look very different to adults. In adults, it shows as rapid speech, high energy, elevated mood, grandiosity and over-confidence. In children, mania is largely irritability and aggression. Is anyone else thinking how many similarities to ADHD in children there are here?

Bipolar depressive symptoms in children

• Sleeping more than usual
• Eating more or less than usual; weight gain or weight loss
• Sadder and more tearful than usual
• Complaints of stomach pains or headaches
• Not wanting to do things they normally enjoy
• Talking about death or suicide; saying they wish they could disappear or go away
• Believing that everyone hates them and they are ‘bad’

Now, as we know, depression is also closely linked to ADHD and the depressive side of bipolar sounds just like that!

So basically, you have a child where mania or heightened activity could be seen as hyperactivity and fidgety, linked to ADHD characteristics. The irritability of mania can look like the low frustration level that is associated with ADHD. Both children with ADHD and bipolar are easily distracted, have emotional dysregulation and have sleep issues! So, how can you tell which one it is or if it’s both?!

When to seek help?

Maybe you have your diagnosis of ADHD and think that all of the above symptoms cover what your child is experiencing. But when is it not just ADHD? As I always say to parents, go with your gut feeling.

1. Is there a history of mental illness in your child’s family?
2. Despite treating ADHD is the problem in their behaviour still interfering with their daily life?
3. Can they play with other children their age or do they feel overwhelmed?
4. Are their demands outweighing what you can cope with?
5. Are they able to attend mainstream school regularly?
6. Does your child worry about things that other children their age don’t even think about?
7. Do they feel like there is something wrong with them?

Obviously, some of these questions are age-dependent. As I always say, keep notes of everything you feel is not quite right.

How is Bipolar Disorder Diagnosed in Children?

There is no single test for bipolar disorder. Doctors usually diagnose it by looking at a person’s symptoms and history. They may ask about your family history of mental illness and whether you have any other medical conditions. They will also do a physical exam to rule out other possible causes of your symptoms. Often they will check for an over or under-active thyroid. Bipolar disorder can often look like ADHD which can make it difficult to diagnose.

The main differences I found were that ADHD tends to be seen earlier in childhood than bipolar. Although obviously there are exceptions to every rule with both. Also, mania comes and goes whereas ADHD is a consistent condition. Mania and depressive episodes generally cluster together and can be days or weeks followed by periods of calm, ADHD is chronic. ‘The risk of recurrence in the 12 months after a mood episode [bipolar mania and depression] is especially high (50% in 1 year, 75% at 4 years, and 10% afterwards per year) compared with other psychiatric disorders,’ taken from Nice.org.uk

The difficulty comes with diagnosing children with suspected bipolar because the rules applied to diagnosing adults with bipolar cannot be applied to children. Adults must be seen to have a period of mania for at least seven days. However, children can be anything from a day to three days, much quicker cycles than an adult. Adolescents are generally similar to adult cycles. Also worth noting is that children with bipolar are more likely to experience the lows of the depressive side more frequently than the mania side of bipolar.

Most children who are diagnosed with bipolar disorder are between the ages of 6 and 12 years old. However, it is becoming more common for children as young as 3 years old to be diagnosed. Children with bipolar disorder often go to mainstream schools. However, some may need to go to special schools or be home-schooled.

Speak to your child’s school and SENCO, and go to your GP or Health visitor. See if they are seeing the same behaviours. Ask for a referral to CAMHS (Child and Adolescent Mental Health Services). You really need someone very qualified to make the distinctions between bipolar, ADHD or any other disorder. There do appear to be many overlaps and the correct diagnosis is vital. Care needs to be taken to see if the symptoms are bipolar, ADHD or actually both. Bipolar disorder is a serious condition that can lead to suicide if it’s not treated. With the right treatment, children with bipolar disorder can lead happy, healthy lives.

Treatment for ADHD and Bipolar Disorder in Children

There is no cure for either ADHD or bipolar disorder.

ADHD is usually treated with medication, behavioural therapy, or a combination of both. (see ADHD and Medication and also ADHD and CBT).

Treatment for bipolar disorder usually includes medication and therapy. The goal of treatment is to reduce the severity and frequency of episodes of mania and depression. Children with bipolar may be happy and outgoing one moment, and then suddenly become angry or depressed the next. This can make it difficult for them to function at home, school, or in social situations.

Bipolar Medication

The most common type of treatment for bipolar disorder is medication. Children with bipolar disorder may take one or more mood stabilisers, antipsychotics, or antidepressants. In some cases, a doctor may prescribe a combination of drugs. In very severe cases, a child may need to be hospitalized.

Lithium is a medication that is used to treat bipolar disorder. It can help stabilize mood swings, reduce the risk of suicide, and decrease the number of manic episodes. Lithium can also help prevent depressive episodes. While it is an effective treatment for many people, it does have some side effects, including weight gain, hand tremors, and excessive thirst. Lithium is not normally prescribed to children under 12 years old. There are other mood stabilisers that are approved for children under 12. Obviously, your specialist will tell you all the side effects to weigh up your decision.

Doctors generally advise treating ADHD symptoms first. ADHD stimulant medications work very quickly and can be seen in days or weeks if it is going to work. Then you can work on what symptoms remain if any.

Other treatments that have helped with ADHD and/or bipolar disorder

-Special education services

-Occupational therapy

-Behavioral therapy

-Family therapy

-Support groups

Some children also benefit from complementary treatments, such as omega-3 fatty acids or yoga. Talk to your doctor to see if these might be right for your child.

Behavioural therapy can also be helpful for children with ADHD or bipolar disorder. This type of therapy can teach children skills to help them manage their symptoms. Family therapy can also be beneficial, as it can help families understand and support their children.

Parents can also find support groups for themselves and their children. Support groups, as I have found, really let you know that others out there ‘get it’ and can offer you real-life advice or just a virtual shoulder to cry on or vent to.

How can parents help their children with ADHD and bipolar disorder?

There are a few things parents can do to help their children if they have ADHD and bipolar disorder:

• Encourage them to stick to their treatment plan. This may include medication, therapy, or both.
• Help them stay organized and on track with schoolwork and other activities.
• Make sure they get enough exercise and sleep.
• Create a calm, supportive home environment.
• Encourage positive relationships with friends and family.
• Talk to them about their condition and how they’re feeling.

How can the school help a child with bipolar?

The school can help by providing a safe and supportive environment. Teachers and staff can be trained to recognise the signs of ADHD and bipolar disorder and to provide support and accommodations. (See Can a Child be Successful in School for ADHD).

• Ensuring the child understands what they have to do and can do it without stress
• Give the child/teen a safe person to talk to if they need to
• Allocate 1:1 to the child where possible
• Contact parents/carers if a change in behaviour is observed, for example, appearing low in mood or elated.
• Agreeing on a later start on days when sleep has not been possible
• If possible allow the student a quiet space if they are starting to feel overwhelmed with a mood change

Like all comorbidities to ADHD, this sounds really tough so make sure you do reach out for help. Two useful sites I found for bipolar are RCPsych and BipolarUK.