Child Mental Health for Pediatric Clinicians

51. Is it ADHD or Bipolar? with Dr. John Walkup

• Elise Fallucco • Episode 51

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Do you have patients with severe ADHD who are just not getting better?  Did you know that they *might* have undiagnosed bipolar?  

In this episode, Dr. Fallucco and Dr. John Walkup talk about how to distinguish bipolar disorder in children and teens from ADHD. They provide clinical pearls for clinicians and share examples from kids and teens with bipolar.  

Some Key differences between ADHD and BIPOLAR highlighted include :

- the nature of relationships in ADHD vs. BIPOLAR

  • Kids w/ ADHD tend to be fun, likable while kids with BIPOLAR have more serious problems in relationships, including with their own parents

-  extreme impulsivity

  • Kids and teens with Bipolar have more extreme, intense impulsive aggression and emotional reactions

** Early identification and consultation with psychiatry is key to helping support these kids and families best.**

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to Child Mental Health for Pediatric Clinicians. I'm your host, Dr. Elise Fallucco, child psychiatrist, and mom. This week we're continuing our conversation with Dr. John Walkup about bipolar disorder in kids in teens. In our previous episode, number 50, go back and listen.'cause we talked about red flags that children or teens might have to let us know that they may have bipolar. This episode we're gonna share clinical pearls about how do you tell the difference between kids with bipolar and kids with a DHD. I wanna start this with a question for our listeners. How many of you have patients with severe A DHD who you feel like are just not getting better and sometimes feel like maybe they're getting worse? I think this episode may be really helpful for you. Why? Many kids with bipolar go about 10 years before they're finally diagnosed, and in the meantime, they're being treated most often for A DHD. And so it's these kids with more severe A DHD where we really should be thinking about could this possibly be bipolar? So to answer this question, we'll be discussing with Dr. Walkup. How do you tell the difference between A DHD and possible bipolar? Which kids should you possibly suspect for bipolar? What specific things should you ask and look for? And finally, we're gonna share details from real clinical cases of kids and teens that'll help you better recognize. High risk kids, and ultimately the goal is to help recognize these kids early so that they can get referred for treatment and evaluation and ultimately have much better long-term outcomes. So now let's dive into the conversation with Dr. Walkup. John, how common is bipolar in pediatrics?

Dr. John Walkup:

It's not common. It's 1 percent of kids or less. Because if you look at the literature, it takes about a decade to get diagnosed. But I think what happens is these kids are in pediatric practices and they are having trouble and the easiest diagnosis to give them is ADHD but it just, doesn't grab them doesn't fit the picture very well. The kids we want to think about are the kind of early pre pubertal kids they don't really fit ADHD by history, and they're different, and they're really beginning to run into functional problems, and they have qualitative differences in some of these characteristics.

Dr. Elise Fallucco:

Since kids with undiagnosed bipolar could be walking around with a diagnosis of A DHD, let's talk about what types of things would make you worry about bipolar in somebody with a diagnosis of a DH. D.

Dr. John Walkup:

You know everybody loves the ADHD kid even though he's not on stimulants. They're fun, they're funny, they're in the world with you, you can relate to them, they just have a hard time managing themselves.

Dr. Elise Fallucco:

they're fun loving, they're class clowns they're very likable typically.

Dr. John Walkup:

but The bipolar kids burn up relationships in the way that no other disorder burns up relationships. People are tired of them. They wear out relationships. And and so they even wear out their relationship with their parents. And it's very hard for parents to Give up on their kids a little bit, but these are kids where parents are on that edge where they just, they don't understand their kid. They can't manage their kid and the lack of engagement and the lack of responsiveness. The lack of respect for the relationship, all of that kind of goes out the window with bipolar disorder, because again, these folks are above it all.

Dr. Elise Fallucco:

think clinically of some of the kids, especially teenagers with bipolar who I've treated That rings true, like being in the room with some of them, when they're not very well controlled and struggling is hard because, they're very irritable. And irritable plus impulsivity is not a great combination. And so I've had some of them just insult me in the room. Like it's not a big deal. Multiple times, actually, usually on what I'm wearing, which is probably fair. They don't care that I'm here to help them, and that maybe they should be a little bit respectful, it doesn't matter to them

Dr. John Walkup:

Increasingly the bipolar kids I see are coming in because they don't care. School doesn't matter, peers don't matter, consequences don't matter, they feel immune to the world around them. And so they make decisions that cost them a lot, and they get themselves into a ton of trouble because they're pursuing their appetites. But they just don't care.

Dr. Elise Fallucco:

Yeah, I want to stop you on the don't care part, I also see commonly in our teenagers, it doesn't matter, I don't know why I'm studying, why do I have to take Spanish in high school? Some of that I think of is somewhat developmentally typical but you're talking about a more extreme thing like, honestly, I'm better than all of this and I can fail out of school and it's not a big deal. And so what I got in trouble with the law.

Dr. John Walkup:

Yeah. It's an obliviousness maybe, as opposed to this kind of feigning of lack of caring about kind of norms and expectations, right? That's what you're talking about in the teenage years. But these are kids who've just they're above it all and stuff just doesn't matter to them in the way that it matters to other kids. And they won't even posit the argument that it's not important. They'll just. Live a life where they act like stuff doesn't matter and the consequences that come with that are pretty significant

Dr. Elise Fallucco:

So they act like they're above it all not because they have any sort of deep philosophical beliefs about required language courses in high school

Dr. John Walkup:

Exactly

Dr. Elise Fallucco:

So you're saying that some of the things that distinguish kids with bipolar from kids with A DHD are that the kids with bipolar don't care about consequences and they live like that. You're also saying they burn up relationships, meaning that they have a hard time keeping relationships with their friends and even with their parents. So now let's talk about how does impulsivity look different in kids with bipolar compared with kids with A-D-H-D-I.

Dr. John Walkup:

The impulsivity for people with bipolar disorder is very different than the impulsivity that you see with ADHD.

Dr. Elise Fallucco:

So impulsivity in ADHD is more the kind of blurts out answers can't keep their hands to themselves, when they're really at the end of their rope, they're more likely to, maybe toss out some insults or potentially it could be a little bit of impulsive aggression, getting into fights at school when provoked, whereas the impulsivity that we would see with bipolar is much, much more extreme. I almost think about the nervous system, like with our. Deep tendon reflexes are like you're, when you use the special hammer to hit your knee, that a kid with ADHD would have, a, maybe a little bit of a brisk reflex, and would respond to provocation or some stressor or trigger. Whereas a kid. With bipolar has major obvious hyper reflexivity. Like you don't even, you get the hammer, like slightly near to the tendon and they're kicking somebody in the next room, even the slightest provocation, as you put it can send them over the edge.

Dr. John Walkup:

It's speed, it's intensity, it's end point, and it's qualitatively different. And bipolar patients aren't even hyperactive sometimes. They're just extremely impulsive and goal driven around, around their grandiosity and their appetites. and I just, I think once you see it, you get a feel for it. And what we're trying to do with pediatricians is we're trying to get them to have a feel for that unrecognized bipolar disorder.

Dr. Elise Fallucco:

Right.

Dr. John Walkup:

And it's those kids that we want the pediatricians to take a step back from and just say, Ooh, is this one of those kids? Let me call my psych consultant and just put this kid on their radar this is a kid I'm going to flag and monitor a little bit more closely because this kid's got some of those early subsyndromal symptoms of mania, grandiosity.

Dr. Elise Fallucco:

We're trying to help pediatric clinicians figure out which are these cases that could possibly be high risk for bipolar or be early signs of bipolar. So let's anchor this with an actual clinical case. I'm thinking of a teenage girl who was really interested in art. And so she would stay up all night working on these pictures and these abstract paintings and It would be like three in the morning and she didn't even feel tired, but was like I should probably take a little break and would sleep for an hour or two. And again, wake up and immediately it's I've got to get back to the paintings. And then she would bring the paintings to the session. And it was very interesting. It's not like she's having trouble falling asleep because she's worried. It's not that she's so hyper so much. It's that she has a goal, which is making these paintings, and that's overriding everything else and seems more important. And, immediately when she pops awake, she's back to the goal.

Dr. John Walkup:

And the thing that's tough for some parents sometimes is sometimes that artwork is quite extraordinary. I've seen stuff by six, seven and eight year olds. That I look at and I'm like, Oh my gosh, the mind that's creating these beautiful things is really quite extraordinary, but they can't stop and they're added for extended periods of time and it stops being something that's part of a creative process. It's more like they just have to, they have to ooze out this stuff and just do it everywhere. And I think those cases are easier, but even those cases don't get diagnosed. And sometimes what happens is they get defended. She's a great artist, for example. We don't want to kill the artistic capability, but the kid's not sleeping. They may not be doing what they need to be doing in school. They've lost balance or perspective. And so the art may be at the extraordinary level, but it's their functioning is at the impaired level.

Dr. Elise Fallucco:

Yeah. And that's what we have to look at that. If it were really just part of a creative process, we wouldn't necessarily think that they wouldn't be able to function in other settings at school or at work or, wherever they are. So any last words of wisdom about bipolar for our pediatric colleagues?

Dr. John Walkup:

It's really this group of kind of floaty, not very functional, talented, little off putting, High appetites, that group of kids, you should just have this little index of suspicion that maybe there's something going on and you call your consultant. You put a flag on the chart. you're just going to want to watch this a little bit closer and begin to think about collecting vignettes and stories about who this kid is because the pattern gets put together through vignettes and stories. It's not. I want to be Superman, but it's, I want to be Superman and I'm only sleeping four hours. I wake up on a instant I'm particularly provoked by sexual behavior on television. And I'm thinking about being a millionaire someday. Okay, now we've got little vignettes that are all beginning to come together. And oh, by the way, he's has trouble making friends. He could start friendships, but his friendships don't last very long because he burns them up. There's just things like that, that I want pediatricians to be sensitive to. Because if we get to these kids really early, We can probably treat them in a low intensity way and bring them down and then spend some time working with that family to understand what the kids struggle really is going to be and then we can put together a life plan for those kids.

Dr. Elise Fallucco:

Thank you for all of your clinical pearls and words of wisdom about, what is and what isn't bipolar and what can we do to make sure that We get on top of things early and if need be, refer them for evaluation.

Dr. John Walkup:

That's the dream. Get to them early. That is the dream. This is why we do what we do. And I think it's also helpful because I know all clinicians can get really frustrated when you have these kids. You're like, I think it's ADHD and we're trying to treat them. And some parts are getting better, but not, and we're still having all of these problems. And I don't know what this is. And so this is helpful to be able to do a clinical evaluation and try to determine, is this a kid that could be possible bipolar

Dr. Elise Fallucco:

And as a final recap for our friends and colleagues of the podcast, Here are things that distinguish kids with bipolar from kids with just a DH. D. One, their relationships. Kids with bipolar are much more likely to have trouble in re relationships or to burn up relationships, whereas kids with A DHD tend to be generally likable and usually not have as many problems maintaining friendships. Two kids with bipolar live like they don't care about the consequences. Three kids with bipolar have much more extreme impulsivity than kids with A DHD. They tend to be much more reactive with their emotions or even potentially with aggression, and this can cause bigger problems. And then four, something that's unique to kids with bipolar are that they have this intense drive. To do whatever is their pleasurable activity. Like the case that we gave was painting, but it really could be whichever idiosyncratic interest that a child or teenager may have, and this drive overrides even their need for sleep if you were bopping around and did not take notes on this episode, but you wanna remember some of the key features, please visit our website psyched for peds.com. So that's P-S-Y-C-H-E-D, the number four peds, where we will have little posts on the difference between A DHD and bipolar. Please also become a friend and colleague of Psyched for Peds, where we will go ahead and directly email you this every time we have an episode that comes out. We hope you'll join us next time on the pod. Take care.