Shirah Vollmer MD

The Musings of Dr. Vollmer

Is It Severe ADHD or Childhoood Bipolar? The Case For A Longitudinal Assessment

Posted by Dr. Vollmer on November 10, 2011

Alan, now eleven, has seen me since he was four years old. Zane, his dad, was diagnosed with ADHD when he was thirty. Zane does well on stimulants, such that he reports that “they changed my life.” Theresa, Alan’s mom is a speech therapist, specializing in children with special needs. Beth, their younger child, has no issues that concern them. By contrast,seven years ago,  Zane and Theresa reported that Alan’s behavior was “really not normal.” They continued to state “his moods shift rapidly. “We cannot handle him. We think there is something seriously wrong with him. He gets upset at the slightest thing. He is not like the other kids. He throws chairs when he does not get his way. He cannot focus on “anything he has no interest in.  We know he is smart, but that does not seem to help him. His tantrums are simply out of control. Maybe he is bipolar or something.” Theresa tells me her frustrations with Alan, with tears in her eyes and a look of deep concern. “I work with special needs kids, but I have never seen anything like this,” she tells me.

I do my usual investigative work: I talk with Alan’s teachers. I see Alan myself. I gather more information from concerned relatives. Based on my review of the history and my observations of Alan, I conclude that he has ADHD and he needs a stimulant. We do a stimulant trial and Alan gets worse. “You see,” Theresa tells me, there is something else going on.” “Not necessarily,” I explain. The fact that he did not respond to stimulants may mean that his brain is too young to reap the benefit, so that maybe as his brain matures, he will be able to handle a stimulant better.” I explain. Theresa and Zane are not convinced.

  Fast forward five years, and we repeat a stimulant trial only this time, it is a remarkable success. Alan is doing better handling frustration and focusing at school. Fast forward two more years, and Alan is back to where he was at four, only now he is approaching puberty. Once again, Theresa and Zane believe that his behavior cannot be explained by ADHD alone. They are deeply concerned about  whether Alan has a chronic mental illness such as bipolar disorder, even though there is no known family history of this diagnosis. “I think he needs a higher dose of his stimulants. I also think that puberty has exacerbated his mental state, such that with time, his brain will mature and his frustration tolerance will improve.” I explain, again, not convinced that his low frustration tolerance is related to childhood bipolar disorder.

  Alan only tantrums when he does not get his way; when he is not the center of attention. Theresa and Zane are admirable parents, but they need to understand that raising Alan is more demanding because of the severity of Alan’s ADHD. They need to work harder at  providing consistency and structure. We have talked about these parenting skills and they are on board, but still skeptical of Alan’s future mental functioning. “I think time is going to be on our side,” I say, explaining the wonders of maturation. “Medication will also help,” I say, agreeing with them, that parenting alone is insufficient to deal with the severity of Alan’s behavior.

Theresa and Zane, after much discussion, feel a bit relieved that we are still dealing with the same issues that we were dealing with seven years ago. Alan too, looks forward to increasing his medication, as he says “I don’t like that I behave this way. I really don’t,” with shocking insight into his difficulties. There is hope in the air. We will see how it goes.

2 Responses to “Is It Severe ADHD or Childhoood Bipolar? The Case For A Longitudinal Assessment”

  1. Shelly said

    Does bipolar disorder only show up only if there is a family history of it? If there is no parental history, can their children be guaranteed not to have it? How did Zane and Theresa survive 7 years of Alan’s tantruming? Do sentences like, “They need to work harder at providing consistency and structure” sound like you’re blaming the parents? Which medications do you feel would be helpful in managing Alan’s case?

    • Bipolar in young children is very rare without a family history of bipolar disorder. There are no guarantees, but this is a good general principle. How any parent survives the stress of their children is always a good question. I don’t think that Alan and Theresa felt blamed, but maybe they did. I do think they understood that parenting is more challenging with a child who has extremely little frustration tolerance. Alan needed an aggressive treatment with stimulants. Stimulants did not help him at four, but by six they became very useful, and critical medications, both to his self-esteem and to his ability to stay in school.

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