Copyright ª Blackwell Munksgaard 2006

Bipolar Disorders 2006: 8: 182–187 BIPOLAR DISORDERS

Brief Report

Comorbidity of attention deficit hyperactivity

disorder in juvenile bipolar disorder
Jaideep T, Reddy YCJ, Srinath S. Comorbidity of attention deficit T Jaideep, YC Janardhan Reddy and
hyperactivity disorder in juvenile bipolar disorder. S Srinath
Bipolar Disord 2006: 8: 182–187. ª Blackwell Munksgaard, 2006
Department of Psychiatry, National Institute of
Mental Health and Neurosciences (NIMHANS),
Objective: There is some evidence to suggest that attention deficit Bangalore, India
hyperactivity disorder (ADHD) and juvenile bipolar disorder could be
related. This is based on studies of comorbidity and some preliminary
family study data. However, doubts continue to be raised about the
relationship between the two disorders. This study examined the
comorbidity of disruptive behavior disorders (DBD) that include
ADHD, oppositional defiant disorder (ODD) and conduct disorder (CD)
in juvenile bipolar disorder.

Method: Seventy-three subjects with onset of bipolar disorder at age

18 years or younger were evaluated using structured interviews (Missouri
Assessment of Genetics Interview for Children, Structured Clinical
Interview for DSM-IV Axis I disorders – Clinician Version, and
Operational Criteria Checklist for Psychotic Disorders version 3.4).
Information was collected from subjects as well as from their parents.
Patients with comorbid DBD were compared with patients without
Key words: adolescents – attention-deficit
DBD.
hyperactivity disorder – bipolar disorder –
children – disruptive behavior disorders – juvenile
Results: Ten subjects (14%) had one or more comorbid DBD. ADHD,
CD, and ODD were present in three (4%), two (3%), and eight (11%)
Received 2 December 2004, revised and accepted
subjects, respectively. Those with DBD had earlier onset of bipolar
for publication 3 November 2005
disorder and spent more time ill compared to those without DBD.
Corresponding author: Dr YC Janardhan Reddy,
Conclusions: The rates of comorbid DBD in juvenile bipolar disorder Department of Psychiatry, National Institute of
are low. The study does not support a definite relationship between Mental Health and Neurosciences (NIMHANS),
ADHD and juvenile bipolar disorder. Higher rates reported previously Hosur Road, Bangalore 560029, India.
may be due to differing methods of subject ascertainment. Samples Fax: +91 80 26564822;
recruited from community and general psychiatric settings may help to e-mail: jreddy@nimhans.kar.nic.in (or)
clarify the relationship between bipolar disorder and ADHD. ycjreddy@yahoo.com

A diagnosis of bipolar disorder (BD) in children
and adolescents had long been a subject of
controversy. It is now widely recognized that BD
is diagnosable in juvenile populations with existing
adult criteria (1). However, the developmental
variations in the symptom manifestation are still
an issue (2, 3). In the last decade there has been
considerable interest in the possibility of a rela-
tionship between attention-deficit hyperactivity
The authors of this paper do not have any commercial associations
that might pose a conflict of interest in connection with this manu-
script.
182
disorder (ADHD) and juvenile BD. Evidence
supporting a relationship between ADHD and
juvenile BD comes from several sources. First,
some studies have reported a very high rate of
comorbid ADHD in juvenile BD patients. These
rates range from 86% to 98% in children (4–7) and
from 20% to 69% in adolescents (5, 8–12). Second,
a few family studies of ADHD and BD have
contributed to the idea that ADHD and BD could
share common familial risk factors (13–15). Third,
neuropharmacological, neuropsychological and
neuroimaging studies have reported somewhat
similar, although not specific, findings in both
ADHD and BD subjects suggesting either a shared

pathophysiology or a common underlying deficit
(16). Lastly, a follow-up study of children with
ADHD reported a high rate of BD (17), but in
another longitudinal study there was no increased
risk of BD (18).
Despite the evidence from these studies, doubts
have been raised about the relationship between
ADHD and juvenile BD (16, 19). Previous studies
from this center have reported very low rates of
ADHD in juvenile BD (up to 11%) raising doubts
about the relationship between the two disorders
(20–24). However, a major limitation of these
studies was the relatively small sample sizes with
the exception of one chart-based retrospective
study (23). A high rate of ADHD comorbidity in
previous studies of juvenile BD has also been
attributed to the ascertainment bias (19), and the
operational diagnostic overlap between ADHD
and BD (16). One concern is that a majority of the
relevant literature reports are from a few tertiary
hospitals in the United States and therefore,
external replication is required (16). In view of
the continuing uncertainty about the comorbidity
of ADHD in juvenile BD, this study examined the
rate of ADHD and other disruptive behavior
disorders (DBD) in a relatively large sample of
young patients with BD who have had their first
bipolar episode before the age of 18 years.
Method
Subjects
Seventy-three subjects with BD with onset at age
18 years or earlier and current age of 25 years old
or younger formed the sample of this study. We
used an arbitrary cutoff age of 25 years to ensure
that parents of subjects included in the study were
available for interviews and to minimize problems
with recall of childhood information. The older the
patient, the information about childhood was less
reliable. The subjects were recruited in the year
2002 from the Child and Adolescent Psychiatry
(CAP) services and an adult unit of the National
Institute of Mental Health and Neurosciences
(NIMHANS), Bangalore, India. The CAP unit
caters to the needs of children younger than
16 years of age and those older than 16 are treated
in adult units. Written informed consent was
obtained from the subjects and their parents.
Assessment
All the subjects underwent extensive evaluation to
confirm the diagnosis of BD. The principal author
interviewed all the subjects using structured inter-
Comorbidity of ADHD in BD
views. Subjects younger than 18 years (n ¼ 38,
52%) were evaluated using the Missouri Assess-
ment of Genetics Interview for Children (MAGIC)
(25) and those 18 years and older (n ¼ 35, 48%)
were assessed using the mood disorders and
psychotic symptom modules of the Structured
Clinical Interview for DSM-IV Axis I disorders –
Clinician Version (SCID-CV) (26). The SCID-CV
does not have modules for ADHD, ODD, and CD.
The MAGIC is a revised version of the Diagnostic
Interview for Children and Adolescents (DICA)
(27). It is a polydiagnostic, semi-structured inter-
view which generates DSM-IV diagnoses. We
preferred the MAGIC over other instruments
because we were trained in using it and its previous
version, the DICA. The instrument covers individ-
ual symptoms of DBD in great detail by asking
questions about the frequency of their occurrence,
the settings in which they manifest, and the degree
of impairment caused in academics and in rela-
tionships with peers, teachers and family members.
The MAGIC has three versions: the child version
(7–12 years), the adolescent version (13–17 years),
and the parent version. Subjects were assessed
using the child/adolescent version and the parent
version was administered to the subjectsÕ parent(s).
Based on the ratings of the child/adolescent and
the parent versions, the clinician arrived at a final
rating of all the individual items. For adult subjects
who were assessed using the SCID, collateral
information was obtained from parents through a
detailed, unstructured clinical evaluation. Further,
the Operational Criteria Checklist for Psychotic
Disorders version 3.4 (OPCRIT) (28) was applied
to the existing clinical charts. A diagnosis of
juvenile onset BD was made according to DSM-
IV criteria by consensus of two clinicians (TJ &
YCJR or TJ & SS) by reviewing all the available
information from structured interview data, clin-
ical charts and the OPCRIT. Life course of BD was
determined by using information from all the
sources according to the Life Charting method
(29). Episode polarity, episode duration, remission,
relapse, recurrence, and cycling were established
using the DSM-IV definitions.
All the subjects were evaluated for the lifetime
diagnosis of ADHD, conduct disorder (CD) and
oppositional defiant disorder (ODD) by adminis-
tering both the child/adolescent and parent version
of the MAGIC. The assessments were made when
the patients were not in an acute affective episode
to ensure cooperation and to avoid the confound-
ing effect of the current episode on the recall of
symptoms pertaining to DBD. Patients did not
have arousal symptoms of mania or psychotic
features at the time of assessment. Adult subjects
183
Jaideep et al.

were assessed with the adolescent version of the Table 1. Sociodemographic and clinical characteristics of the sample
MAGIC since the method of elicitation of life- (n ¼ 73)
time DBD does not differ in adolescents and adults Frequency/ Percentage/
(W. Reich, personal communication). We chose mean SD
MAGIC over self-rated instruments to diagnose
Gender
DBD for two reasons. First, the purpose of this Male 27 37
study was to make lifetime diagnoses. For this, Female 46 63
MAGIC was ideal because it covers DBD Age in yearsa 16.79 3.74
symptoms, both current and lifetime, extensively. Background
Second, it was possible to obtain collateral infor- Rural 43 59
Urban 30 41
mation from the parent(s) by administering the Occupation
parent version. It is well known that parents are Student 33 45
more reliable informants than index subjects for Housewife 6 8
diagnosing psychiatric problems in children, par- Agriculture 10 14
ticularly externalizing disorders (30). Based on the Unemployed 15 21
Other 9 12
ratings of the subject and parent, the final rating of Years of education 8.03 3.11
the individual items was made by the principal Age at onset of bipolarity (years) 14.68 2.60
author. Wherever major discrepancies arose, clar- First episode polarity
ifications were sought from the parent and the Mania 51 70
subject before the final rating was arrived at. A Hypomania 2 3
Depression 17 23
final diagnosis of DBD was made by the consensus Mixed 3 4
opinion of the two clinicians (TJ & YCJR). Total number of episodes 2.58 2.28
Subjects with single manic episode 25 34
Number of weeks ill in a year 21.32 22.31
Results Comorbid lifetime DBD
Attention deficit hyperactivity 3 4
A majority of the sample was self-referred and never disorder
treated (n ¼ 58, 80%) at the time of first consulta- Conduct disorder 2 3
tion at NIMHANS. Sociodemographic and clinical Oppositional defiant disorder 8 11
characteristics of the sample are given in Table 1. Any DBD 10 14
Female subjects were overrepresented in the sample.
DBD ¼ disruptive behavior disorders.
The sample had 12 subjects (16%) with onset in a
Range ¼ 18 years; minimum 6 years, maximum 24 years.
childhood (12 years or younger). For most subjects,
their first episode was mania (n ¼ 51, 70%). There
were only three subjects with bipolar II disorder Those with comorbid DBD had earlier onset of
(4%). It is evident from the table that the rate of BD compared with those without comorbid DBD.
DBD (14%) including ADHD (4%) was very low in A low rate of ADHD in this sample is not in
this sample. None of the subjects had been previ- accordance with the findings of most previous
ously diagnosed as DBD. None were treated previ- studies that have reported rates ranging from
ously with stimulants. The subjects with any DBD 86% to 98% in children (4–7) and from 21% to
(n ¼ 10) were compared with those without DBD 69% in adolescents (5, 8–12). However, our
(n ¼ 63) using the Mann-Whitney U-test as the finding is comparable to the findings of previous
sample data was not normally distributed. Those studies from this center, which found ADHD
with DBD were younger (14.20 ± 3.05 years versus rates of 0–11% (20–24). This rate is also compa-
17.21 ± 3.69 years, U ¼ 159.5, W ¼ 214.5, Z ¼ rable to the 6–9% rate of hyperkinetic disorder in
)2.515, p ¼ 0.012), had earlier onset of BD the clinic population of this hospital (31) and
(13.30 ± 2.26 years versus 14.90 ± 2.59 years, 1.6% (urban 3.7%, rural 0.5%, slums 1.2%)
U ¼ 194, W ¼ 249, Z ¼ )1.961, p ¼ 0.05), and reported in a recent community-based study from
spent more time ill per year (40.93 ± 35.20 weeks this center (32). General population studies that
versus 18.16 ± 17.99 weeks, U ¼ 174.5, W ¼ have employed DSM-IV criteria have reported
2127.5, Z ¼ )2.288, p ¼ 0.027) than those without somewhat similar rates ranging from 5% to 10%
DBD. (33, 34).
We discuss the possibilities that may account for
the discrepancy in the rate of ADHD compared
Discussion
with other samples. The most important and often
The main finding of the study is the low rates of neglected explanation could be ascertainment bias.
ADHD, CD, and ODD in juvenile onset BD. Previous studies mostly included referred subjects
184

from tertiary centers and special clinics (7). Such
subjects could be suffering from severe forms of
illness and from multiple comorbidities resulting in
obvious ascertainment bias. This means that only
in a small sub-group of BD patients the comor-
bidity of ADHD could be high. In contrast, the
subjects in this study were largely self-referred,
never treated before and were not recruited from
special clinical settings. Thus, it is likely that our
sample is closer to a general population sample of
adolescents with BD. A related issue that could
have contributed to the low rate of ADHD in our
study is the possibility of underreporting of mild
ADHD. Our sample had predominantly rural
subjects, and a majority of them did not attend
school despite their young age. Moreover, a
substantial proportion of them were either farmers
or unemployed. It is likely that mild ADHD does
not cause much impairment in these settings, and
therefore is not recognized as a problem.
An overlap of operational diagnostic criteria
for ADHD and BD could also contribute to high
rates of ADHD in BD, particularly in children.
This remains a fundamental methodological limi-
tation when ADHD is assessed in children with
BD (16). Recently there have been efforts to prove
that higher rates of BD in children with ADHD
are not due to artifacts from overlapping symp-
toms by removing these overlapping symptoms
from diagnostic procedures (35). Another
approach employed is to use elation and/or
grandiosity as necessary inclusion criteria to
diagnose BD (6). This is an interesting but
controversial approach (16). In the study by
Geller et al. (6) narrower criteria are employed,
but the possibility of overdiagnosis of ADHD in
BD persists because of symptom overlap. In
addition, their interpretation of behaviors that
constitute ÔelationÕ and ÔgrandiosityÕ are not neces-
sarily similar to those of others. It is possible that
differing interpretations of what behavior fulfills a
symptom criteria also, to some extent, contributes
to discrepancies between studies regarding ADHD
and bipolar comorbidity. The subjects of Geller
et al. had unusually high rates of ultradian
cycling. Aside from the fact that ultradian cycling
is not a well-validated concept (involving at least
365 episodes per year in which mania occurs for
at least 4 h at a time), it is difficult to differentiate
ultradian cycling from the affective/temperamen-
tal instability that is part of the ADHD clinical
picture. Therefore, it is possible that severely ill
children with ADHD get an additional diagnosis
of mania. Additionally, the bipolar phenotype
described in some of these studies does not fit the
classic definition of mania well (36). While it
Comorbidity of ADHD in BD
could be argued that the classic episodic course is
not typical of childhood BD, experts agree that
BD could be diagnosed in children by using DSM
criteria (1). In our study, there was a typical
episodic course with clear onset of BD symptoms
at a much later age than the onset of ADHD. In
the majority of subjects, the index episode was
mania with low rates of mixed and depressive
episodes. A low rate of depression is unlikely to
be due to underdiagnosis because this has been
replicated in previous studies from this center
(21–23). It is possible that the early-onset BD in
India is somewhat phenotypically different from
that in Western countries.
We found a younger age at onset of bipolar
episodes in those with comorbid DBD. This finding
is consistent with that of previous studies (24, 37),
but it is preliminary and has to be viewed with
caution because of the small number of subjects
with DBD.
The main strength of this study is the availa-
bility of information from both the patients and
their parents obtained by using structured inter-
views. In some studies, information was obtained
mainly from a parent, and this may have resulted
in an artificial increase in the reported rates of
comorbid ADHD and BD since symptoms of
both the disorders may appear essentially the
same to the parent (38, 39). An additional
strength of the study is that a clinician conducted
the interviews and the diagnoses were confirmed
by a consensus of two psychiatrists using all the
available information. The study has certain
limitations. First, the sample included mainly
subjects with adolescent-onset BD. Despite this
limitation, the rate of ADHD in this sample is
much lower compared with the high rates report-
ed in other adolescent samples. Second, the
retrospective recall of mild to moderate ADHD
symptoms may not be very reliable, resulting in
possible underdiagnosis. To an extent, this was
addressed by obtaining information when subjects
were not in an acute episode. Third, our sample
was overrepresented by female subjects. This may
have contributed to low rates of DBD because
DBD are more common in boys.
Conclusion
The present study does not support a definite
relationship between adolescent-onset BD and
ADHD. However, the issue needs to be examined
by large, prospective, community-based studies
with an adequate number of subjects with child-
hood-onset BD. Replication across different cul-
tures is essential.
185
Jaideep et al.
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