The important feature of mania is the way these children appear driven by their wishes or interests. They disregard the wishes of others and the rules of adults. The children are not being oppositional, because the purpose of their behavior is not to argue with or defy adults. The children are single-minded at the moment of mania; they want what they want immediately. In the examiner's office, this is evident by the child's disregard of the doctor's questions and the child's determination to talk, touch, or walk around as he or she pleases. These children, however, interact with the examiner and exhibit some social skills, so they would not be diagnosed in the autistic spectrum.

Rather, when an issue comes up which they are passionate about, whether in response to a question by the examiner or in response to a thought in their head, they pursue the subject with zeal. If the examiner tries to interrupt or stop them, they often react with anger, and they disregard the examiner's wishes. The anger can be exhibited as loud talking, tantrums (by younger children), or a total tuning out of the examiner. Rather than elation, we would call this key symptom "impulsive pleasure seeking." This is more descriptive of the actual behavior of a bipolar child. Sometimes the child may feel elated, but at other times he is full of rage, particularly when his pleasure-seeking behavior is interrupted by adults. While the child's emotion can vary between elation and rage, the single-mindedness or total fascination with some desire or interest is paramount.

The other key characteristic in DSM-IV's criteria for adult mania and also found by Geller in her study of manic children is grandiosity. Grandiosity is more apparent with adolescents who talk about their love interest or their interest in a game or activity, which they feel is the most important thing in the world. The use of superlatives by these adolescents to describe their interests helps confirm the diagnosis. Younger children, however, do not usually talk in a grandiose way. The examiner must discern this characteristic from the way the child is so consumed by what he wants to do and so oblivious to the needs of others. This total self-centeredness is a sign of the younger child's grandiosity.

The authors have focused this discussion on mania, rather than on the other pole in bipolar disorder: depression. The main reason is that depression is not prevalent in pediatric cases. Only a small percentage of bipolar children experience depression. Whereas about half of bipolar adults experience periods of depression, most of the bipolar children cycle between pleasure seeking and anger and relative calm.

Bipolar Disorder with ADHD

ADHD symptoms like distractibility and impulsivity occur in most bipolar children as well. Why not just diagnose these children with bipolar disorder and leave out ADHD as an additional diagnosis? One reason is that treatment may be ineffective if the possibility of ADHD is not also considered. Most children who have bipolar disorder and who could also have ADHD are treated for bipolar disorder first. If the symptoms of distractibility and impulsivity improve, then the diagnosis of ADHD would be dropped. However, in a number of cases, distractibility and impulsivity remain a problem even when there is effective treatment for bipolar disorder. The classic ADHD symptoms need to be treated in these cases as well. Thus, at the beginning of treatment, all potential diagnoses should be considered, and many of these children will be diagnosed with comorbid ADHD. The rate of ADHD in bipolar children ranges from 30% in some studies to 90% in others. The higher percentages are found in studies of younger, prepubertal cases and in studies of patients at university psychiatry clinics, where more difficult cases are likely to seek treatment.

Another reason to consider a dual diagnosis is that the degree of distractibility and impulsivity is sometimes more severe and pervasive than if there were only one disorder. For example, impulsivity for ADHD usually does not lead to daredevil acts the way it does for bipolar children. Likewise, bipolar children without ADHD usually only have episodic impulsivity when they are in a manic phase. However, in dual diagnosis cases, the impulsivity is usually persistent throughout the day and to a high degree, not occur just when the child is manic. Likewise, distractibility does not occur just when the child is in the manic phase. It is persistent throughout the day.

Clinical researchers like Biederman, Russell, Soriano, Wozniak, and Faraone (1998) and Gied (2000) support the position that a dual diagnosis is needed in many cases. Gied notes that analyzing family history and brain imaging studies may help doctors determine which children have both disorders. Family history often shows the occurrence of ADHD and mood problems like bipolar disorder in the family tree of one or both parents of children with dual diagnoses. However, children with only ADHD had family trees where ADHD was present but not bipolar illness. Brain imaging studies are in their infancy for these disorders, but early reports indicate different areas of the brain are affected in bipolar disorder as compared to ADHD.

Psychological Treatment Strategies

Therapy involves a combination of individual and family approaches. The aim of individual therapy is to help the child recognize the risks of his pleasure-seeking behaviors and to encourage the child to consider the consequences of his actions. The goal is for the child to display greater balance in his decision-making. Although pleasure-seeking behavior would not be eliminated, the risks would be considered more often, and this would lead to safer and more balanced behavior. Typical pleasure-seeking behaviors for adolescents would be drug use and sex, while for younger children the issue is often risky physical behaviors, like wrestling moves, skateboarding off hills, or climbing trees or onto roofs.

In dual diagnosis cases, excessive risk-taking and impulsivity are more frequent and severe than for one diagnosis alone, and thus it is more difficult for the child to control these behaviors. The therapist and the parent need to be patient but persistent. In order to "keep an alliance" with the child, the therapist must empathize with the difficultly the child has in controlling impulsivity. Keeping an alliance while also encouraging the child to evaluate and reconsider the degree of risk-taking is a balancing act for the therapist who cannot become too didactic and critical of missteps. At the same time, therapy needs to be focused on risky and impulsive behaviors, as these are the crux of what is dangerous for the child.

For the adolescent, the risky behaviors he may talk about are sex and drinking. The therapist first listens and then tries to understand the circumstances and what the adolescent's needs are. At the same time, the therapist wonders out loud how else the adolescent could meet some of his needs without taking on too much risk. For example, the therapist might remark: "You took a big chance there. I wonder how you could have had a good time and gotten everyone to have fun with you without drinking."

It is harder for younger children to talk reflectively about their out of control behavior. When these children are in the office, they are often relatively calm and not interested in talking about their earlier manic behavior. Sometimes the therapist can point out the dangers in a caring way. For example, the therapist might remark: "Wow, you could have been hit by a car when you were skateboarding so fast down your street. Are there any skate parks near where you live, or do any of your friends have a cool ramp?" Another possible moment to make a brief reflective comment about risks is when the child gets revved up playing a game in the therapist's office. When the child, in frustration, starts pushing a game board into the therapist's leg, the therapist might say: "Ouch. Do you really want to hurt me?" Another possible remark would be to comment on the child's overflowing excitement: "You are really excited about this game." If the child is calm enough to listen, you could add: "When you push too hard, I really feel like stopping. Maybe go a little easier on me." If nothing is getting through, the therapist might just have to say: "I need to take a break" and pause until the child is a little less revved up. Individual therapy with younger bipolar children often revolves around games, and is only helpful over many months, which is extremely costly. Instead, group therapy focusing on self-control issues may be considered for bipolar children in schools or day treatment centers.

In family therapy, risks are also discussed, and a behavior modification approach is used so that there are incentives for safer behaviors as well as consequences for rule violations. For adolescents, rules regarding curfew observance and control of dangerous substances are valued. Less danger is likely if the teenager is home on time and not abusing drugs; thus, these rules are often critical in family treatment. For younger children, completing homework and observance of bedtime rituals are often areas of conflict. Developing a regular routine with meaningful incentives and consequences often takes time to establish. Having a time range (rather than an exact bedtime) and rewarding approximations to the goal in the beginning of treatment are important. Expect some outbursts at times, and be prepared to alter incentives and consequences when they become stale and ineffective. If the goal for the younger child is to reduce physical aggressiveness in school, the teacher could send home a daily checksheet about the child's self-control, and the parent could use a favorite activity, such as use of the computer, as the after school incentive. Since it may be unrealistic to control physical and verbal behavior at the same time; thus, the initial goal is control of physical behavior.

One strategy the therapist teaches the parents is the use of "distraction" when the child is beginning to get angry. It is important that the distracting comment be something which is important to the child; otherwise the bipolar child will ignore it. Another strategy for parents is "setting the scene" for the child. This means that if the child is going to be doing homework, first play a thinking game like chess or concentration, and then try to shift over to homework while the child is in a thinking mode. A third strategy is teaching the child to "self-monitor." If a child is starting to rev up, the parents might label the behavior as red hot and ask the child if he can get himself down to blue hot. In order to use this approach, the parents would first need to introduce it when the child is calm and then use color flashcards in addition to verbal cues to make it more powerful. Many of these strategies are described in more detail in the book by Gottlieb, Shoaf, and Graff (2006).

Medication Approaches

The two main classes of medications which can be used effectively with bipolar children with ADHD are the atypical antipsychotics and the mood stabilizers. The atypical antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone, clozapine, and the chemically different aripiprazole) are preferred over the older antipsychotics, because they usually are easier to tolerate due to their relatively few side effects. They also help reduce agitation, irritability, impulsivity, argumentativeness, and the revved up behavior of bipolar children. There are some possible problematic side effects, such as weight gain and fatigue.

The mood stabilizers include carbamazepine, lamotrigine, lithium, and valproic acid. None of these medications has been approved by the FDA for the use with mania in children under the age of 13, but clinicians are finding that either a mood stabilizer or an antipsychotic medication is helpful in reducing the manic symptoms in children. With the use of mood stabilizers, there needs to be periodic evaluation of blood levels. Lithium, for example, works within a therapeutic range of 0.8 to 1.2 mEq of lithium per liter of blood serum. If the dose is too high, there can be serious side effects, and if the dose is too low, the treatment will be ineffective. Even at low levels of medication, there can be side effects, such as weight gain, acne, nausea, polydipsia, polyuria, and tremor. If these side effects do not decrease in the first few weeks, then the dosage will need to be decreased or medication discontinued.

One question which has not yet been resolved in the treatment of children with bipolar disorder and ADHD is whether to start with an atypical antipsychotic medication or a mood stabilizer. Sometimes, an antipsychotic is tried first, and in other cases, a mood stabilizer is used first. We recommend starting with an antipsychotic in cases where there are rapid shifts of mood in a single day. Most children do not stay in a manic phase for more than a few hours. While a mood stabilizer can be used in these cases, an antipsychotic works faster and there is no need for blood draws as with mood stabilizers.

For many of the children who have bipolar disorder and ADHD, neither a mood stabilizer alone nor an antipsychotic alone seems to resolve all of the problems. Each seems to quiet some of the revved up behaviors in many of these children, but there often continue to be some impulsivity and attention problems. In one small study of bipolar adolescents, some of whom had also been diagnosed with ADHD and some of whom had not, Strober, DeAntonio, Schmidt-Lackner, Freeman, Lampert, and Diamond (1998) reported that those teenagers with a history of ADHD did not improve as much on lithium as the group with had bipolar disorder. About a third of the dual diagnosis cases did not respond to lithium, whereas only ten percent of teens with bipolar disorder alone did not respond. In another preliminary study with a small number of cases, the effectiveness of an atypical antipsychotic (risperidone) was evaluated in dual diagnosis cases (Frazier, Meyer, & Biederman, 1999). The antipsychotic medication was effective for manic symptoms, but not for ADHD symptoms.

Sometimes treatment with two or more medications is necessary for children and adolescents who have bipolar disorder and ADHD. For some children, when a mood stabilizer helps only in part and there continue to be problems with impulsivity and revved up behaviors, the addition of an atypical antipsychotic is effective. Recent studies with adolescents have supported this combination for treatment of adolescent mania (Kafantaris, Dicker, Coletti, & Kane, 2001; DelBello, Schwiers, Rosenberg, & Strakowski, 2002). In our own clinical work, this combination has been found to be effective in cases of bipolar disorder and ADHD.

In other children with ADHD and bipolar illness, stimulant medication may be gradually added to treat distractibility, if that symptom continues, once there has been successful treatment of mood problems with the appropriate mood stabilizer and/or antipsychotic. Depending on the response, the ADHD medications become part of the treatment regimen (Biederman, Mick, Prince, Bostic, Wilens, Spencer, et al., 1999). Biederman and Klein (1998) write that ADHD medications are often needed but that they are only effective after mood stabilization with appropriate medication for mania.

Children and adolescents with bipolar illness and ADHD usually remain on their medications for several years. In the only maintenance treatment study for pediatric bipolar disorder, patients who were maintained on lithium had a significantly lower relapse rate than patients who were not maintained on lithium (Strober, Morrell, Lampert, & Burroughs, 1990). When children or adolescents with bipolar disorder have been without symptoms for several years, the mood stabilizer and/or antipsychotic medication can be tapered gradually over several months and then discontinued. If symptoms recur, then the medications should be restarted.

Summary

Therapy for children with bipolar disorder and ADHD is multifaceted and requires the coordination of therapist, psychiatrist, parents, school personnel, and the child himself. Since there are many upheavals in mood and behavior along the way, and since biological interventions do not always work fully or immediately, there needs to be patience on everyone's part. Psychotherapy involves individual and family therapy which are designed to increase self-control and to reduce risk-taking behaviors. Improvement will be gradual. There can be a tendency by any of the parties to give up, even though treatment is really progressing and just needs time to work more fully. One way to avoid this problem is to set reasonable goals and expectations from the start. Explain to parents that although the child's outbursts or other out of control behaviors will not stop immediately, everyone on the child's team will continue working together on the problem behaviors in therapy and will continue adjusting the medications until a combination is found that is effective. By helping these children develop self-control, clinician, parents, and teachers will have taught them an invaluable tool--self-regulation--that will help prevent more serious problems in adulthood.

This article is based on the book by Dr. David Gottlieb and Dr. Thomas Shoaf in conjunction with Risa Graff, M.A., B.C.E.T. The 2006 book published by McGraw-Hill is entitled: Why Is My child's ADHD Not Better Yet?: Recognizing the Undiagnosed Secondary Conditions That May Be Affecting Your Child's Treatment.

Dr. Gottlieb is a clinical psychologist in private practice in Homewood, Illinois. Dr. Shoaf is a board-certified psychiatrist who works in clinical development in the pharmaceutical industry in Atlanta. Risa Graff is a board-certified educational therapist in private practice in Olympia Fields, Illinois.

References
Biederman, J., & Klein, R. (1998). Resolved: Mania is mistaken for ADHD in prepubertal children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1091-1099.