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Ask the Mental Health Expert Archives 2001-2004

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Ask the Expert - Mixed Diagnosis

Q. I have a 17-year-old daughter who has been diagnosed with several disorders. First, when she was 10, she was diagnosed with ADD and ODD. Now, 7 years later, she has been diagnosed with bipolar disorder. I'm confused about all of this. I was once told that children are often diagnosed with ADHD and ODD but are really bipolar. Can they have both? I'm very worried for her. Next year she will be attending college and I'm not sure she will be able to handle it.

A. Your confusion is understandable, even though it's quite possible that your daughter has been accurately diagnosed at each stage of her development. First, it is certainly possible for a child to have Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Bipolar Disorder (BD). Having one condition doesn't immunize the child from having another.

That said, there is some controversy regarding the relationship between ADHD and BD. Some clinicians believe that ADHD is often incorrectly diagnosed in a child who really is bipolar. Others believe that the two conditions frequently co-occur, perhaps because some underlying genetic or biochemical factor predisposes to both. Indeed, some studies claim that rates of co-existing ADHD and bipolar disorder range from 22% to 90%. Finally, some children may be incorrectly diagnosed as having BD when they are really ADHD kids.

A critical factor in making these discriminations is the phasic or cyclic nature of the child's symptoms. As a rough rule of thumb, kids with ADHD always have the condition, though it may vary in degree from day to day or environment to environment. Kids with bipolar disorder usually show evidence of cycling from month to month or week to week, alternating from depressed/lethargic to manic/irritable, sometimes with periods of quite normal mood and behavior in between mood swings. And of course, kids with both ADHD and BD show a mixture of features that are often hard to tell apart.

If you are in doubt regarding your daughter, I would recommend (if you have not already done so) getting a second opinion at a medical-school based department of child psychiatry. Whatever turns out to be the case, your daughter will need appropriate therapy, support, and most likely, medication. If her diagnosis turns out to be BD, she (and you) may want to contact the National Depressive and Manic-Depressive Association (www.ndmda.org) for links to support groups, information, etc. If she turns out to have ADHD, she may benefit from some special educational counseling/tutoring by a qualified professional, once she gets to college. With optimal support and treatment, she stands a good chance of surmounting these difficulties.

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January 2002

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