Dr. Mota-Castillo is a board-certified psychiatrist in central Florida. He has written extensively on the issue of bipolar disorder in early childhood and is currently working on a book on the topic.
I know it sounds bard to believe, but such a conclusion is a very common finding in past psychiatric evaluations of children. It also seems to be an equal opportunity misdiagnosis because the patient could be a 12-year-old boy from Puerto Rico or a 14-year-old girl from Boston.
Such patients usually come with mania; hypomania or florid psychotic symptoms that are resistant to treatment. Auditory hallucinations in the form of "conversing voices" and serious temper tantrums are also common complaints, along with poor school performance or disruptive behavior. One common denominator is a past history of an attention-deficit/hyperactivity disorder (ADHD) diagnosis followed by a trial with methylphenidate (Ritalin, Concerta, Methylin, Metadate CD).
Puzzled by the pervasiveness of this problem, and troubled by the lack of rationale in giving an ADHD diagnosis to a child whose parents have schizophrenia or bipolar disorder (BD), l began to brainstorm this problem with my staff. Paula, an experienced case manager, made the following comment: "I tell you, no matter what the child has, as soon as they walk in that place, they are [labeled as having] ADHD." She was referring to a local psychiatric clinic that treated patients like "Cindy," a 12-year-old diagnosed with ADHD at the age of 6, despite a family history of mental illness. Various stimulant medications had been tried without success but, at the time of evaluation, Cindy was on 40 mg of methylphenidate and 15 mg of mirtazapine (Remeron). This is part of her mental status examination: "Confused (her mood)…..I can't tell you; I have so many emotions at once … I have a song stuck in my head for a couple [of] days … when I think of one thought another one pops up …yes, I beard-this voice telling me no, no." Cindy's mother reported, "She is always on the run, she does not think before she does, she is very demanding and does not like to be told."
Cindy is a bright, assertive girl going raised by her maternal grandmother Linda, a recovered alcoholic. According to the family history given by Linda, Cindy's biological mother is into drugs and has a violent temper, her maternal great-grandmother was an alcoholic, and her older sister bas poor anger control. Her father’s whereabouts are unknown, but her mother remembers him as being violent and emotionally unstable.
The parents of children like Cindy usually come to my office frustrated and at their wits' end. One of them, "Janet," put it this way, "I am losing it; I feel like I am not a good mother." I had to convince her that it was not her fault, and I compared her son ''Zachary's" delayed response to medication to expecting to put a forest fire out in a few minutes with just a glass of water. Several investigators have documented that prolonged exposure to amphetamines could render antipsychotic drugs ineffective at the beginning of treatment. Several studies have indicated that anty-psychotic efficacy can be delayed by a previous prolonged use of stimulants (Ciraulo et al., 1995) besides, as we all know, amphetamines can mimic the symptoms of paranoid schizophrenia (Jarvit and Zukin, 1991).
Seventeen-year-old Zachary has a family history of mental illness on both sides. His mother bas BD; his father has a history of schizophrenia. When I met Zachary, be complained of auditory hallucinations, thoughts of suicide and being "angry all the time." Current medications were 75 mg of venlafaxine (Effexor) and 25 mg of quetiapine (Seroquel) prescribed by a local psychiatrist who had been told only of Zachary's depressive symptoms. However, there was an extensive history of multiple treatments, including a two-year placement in a residential center (RTC) and more than 20 hospitalizations. In 1999, upon discharge from the RTC, Zachary was on a combination of 11 medications, but that regimen was reduced to only four (quetiapine, olanzapine (Zyprexa), clonidine (Catapress) and guanfacine (Tenex)) before he and his mother moved to Florida. Of note, Zachary reported that he had been sexually molested at the age of 9 (many times over a period of 12 to 14 months), but the investigating authorities accused him of lying. Around that time he was in and out of hospitals due to self-harming (e.g., picking his skin, poking himself with pencils) and stating that he wanted to die. He also stated he had been "bearing voices" for about a year, but had never told anyone. He claimed that no clinician bad ever asked him about hallucinations.
I believe Zachary's story is important because it brings out the issue of false comorbidity. As is typical in such cases, Zachary was first diagnosed with ADHD and oppositional-defiant disorder (ODD). At his mother's request, his doctors added a diagnosis of BD. Consequently, the stimulants were continued.
It is my impression that when faced with a family history that includes BD and schizophrenia we should give strong consideration to deleting the ADHD/ODD diagnoses and treating the child as having just a psychotic illness.
This was especially so in Zachary's case because his hallucinations consisted of three conversing voices and he displayed paranoid behavior. Maybe it is time to get past the fallacy that has made hyperactivity pathognomonic of ADHD. In fact, hyperactivity can be a sign of a multitude of conditions. Moreover the term hyperactive or hyper has many different meanings to different people. For example, one mother said that her son was hyper because he "always was on the go," while another applied the same label to a child who was throwing tantrums and hitting his peers.
Another misconception is that simply because a "hyperactive" child can perform well in a structured setting, be must have ADHD, rather than, say, BD. These supposed ADHD children could actually have a hypomanic mood that responds to clear boundaries, but goes out of control in a poorly supervised situation, like the school bus. This brings out an important point: The child with ADHD wants to be in control but lacks impulse control and cannot filter irrelevant information from the environment. On the other hand, the child with an elevated mood gets a kick out of being mischievous and has no interest in being "good." In technical jargon we could say that the hypomanic child's behavior is, at least transiently, egosyntonic, as well as mood-congruent.
I could cite many other reasons for confusing mood and anxiety disorders with ADHD, but I want to emphasize that prescribing medications like amphetamines could have serious consequences if the diagnosis is wrong.
A dramatic example can be seen in the case of "Francisco," a fourth grader who moved to central Florida from Chicago at the beginning of the year. When he left the Windy City his mother decided to stop this cocktail: lithium (Eskalith, Lithobid), divalproex (Depakote), olanzapine, guanfacine and methylphenidate because, she told me, "He is at his best without medications." He had been diagnosed with ADHD as well as BD based on the presence of hyperactivity, disruptive behavior, mood swings and anger problems. His mother explained that without medications he still had "mood swings" and problems controlling his anger, but his temper tantrums were less intense and he calmed down more easily.
After a thorough evaluation I was convinced that two pieces of critical information could have been overlooked, leading to Francisco's misdiagnosis. First, in 2001, during one of his four hospitalizations, his mother told the attending psychiatrist that the boy was "hearing voices" and seeing "blinking lights," but the professional didn't believe it was true, and his methylphenidate was increased.
Second, the mother described a family history of schizophrenia on both sides. On his maternal side, Francisco's grandmother, a cousin, an uncle and an aunt all suffer from the disorder, as does Francisco's father. At the time of the evaluation, the boy's father was in jail on charges of domestic violence.
The significant improvement shown by Francisco after a few weeks of being just on mood stabilizers made me suspect that we probably need to do a better job of listening when we hear of a significant family history of severe mental illness. By the same token, i.f bizarre behavior, hallucinations, cruelty toward animals or similar symptoms are present, we need to look at diagnoses other than ADHD. The DSM-IV does not list such behavior as ADHD symptoms (American Psychiatric Association, 1994). Just as family practitioners ask about a family history of diabetes or heart problems·. psychiatrists must inquire about family history of mental illness.
Furthermore, we know that stimulants are contraindicated in the presence of psychosis and anxiety. What can we do to avoid the pitfalls described above? The following are some rules followed by our group:
Approach every child with an open mind, regardless of previous diagnoses and treatments. All diagnostic possibilities receive equal attention.
Family history is always taken into consideration.
The diagnostic combinations of ADHD, ODD and conduct disorder usually mean "none of the above" (Mota-Castillo, 2002).
Worsening of symptoms is not an expected outcome of stimulant medications· for ADHD (Mota-Castillo, 2002). Many doctors confuse lack of response (in which case it would be appropriate to increase the stimulant) with exacerbation of aggressive symptoms. This type of response usually indicates an incorrect diagnosis…
The body can have as many illnesses as it pleases. As Pies (1998) stated, we should always be ready to entertain more than one condition at the time of evaluating a set of symptoms or complaints. In other words, a child can have ADHD and posttraumatic stress disorder, ADHD and social anxiety disorder, ADHD and depression, ADHD and history of sexual abuse, and so on. This is relevant because anxiety symptoms will increase when a patient treated with stimulants, among other reasons.
Finally, I would like to emphasize a basic concept that most of us heartily endorse. Children are essentially good, and we always should give them the benefit of the doubt. For example, i.f a child shows sexualized behavior, we think that he or she has been sexually molested or is manic. We don't say, "That child is a pervert." This empathic approach contrasts with the assessment that we make if the same child is demanding, doesn't like to be told what to do or refuses to follow directions. We forget about elevated mood and call such attitudes oppositional-defiant.
That does not sound very fair to me.
American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, D.C.: American Psychiatric Press, Inc.
Ciraulo DA, Shader Rl, Greenblatt DJ, Creelman W (1995), Drug Interactions in Psychiatry, 2nd ed. Baltimore: William & Wilkins.
Javitt DC, Zukin SR (1991), Recent advances in the phencyclidine model of schizophrenia. .Am J Psychiatry 148(1 0) :1301-1308.
Mota-Castillo M (2002), Five red flags that rule out ADHD in children. Current Psychiatry 1(4):56.
Pies R (1998), Consultation Liaison Psychiatry and Psychological Complications of Medical Illnesses. Intensive Psychiatric Board Review Course. CME Multimedia Home Study.