October 1, 2014

Another Day, Another E-Mail: Looking at What Lies Beneath

Author Picture

Patricia O. Quinn, MD

National Center for Girls and Women With ADHD, Washington, DC


Almost every day, I receive an e-mail from a desperate mother. She is writing because she suspects that her daughter has ADHD and is looking for help. In some instances, the girl is young, the symptoms are clear cut and agreed upon by parents and teachers, and mom is just looking for a referral. But, in too many cases, the girl has already been seen by a mental health professional and the diagnosis of ADHD has been missed or mom fears her daughter is misdiagnosed. The following e-mail was received recently and is unfortunately quite typical. (All identifiers have been removed or changed to maintain privacy.)

Dear Dr. Quinn,

My daughter is a sophomore (freshman, senior, etc) at XXXX High School (or College), where she is struggling. She was told by a school counselor (psychologist, psychiatrist) that she is most likely bipolar. She was recently prescribed medication for this diagnosis by a psychiatrist. However, we see her as ADHD: she can be moody and sensitive but has never been really depressed; she starts new projects with enthusiasm, but the follow-through is lacking. She can spend impulsively, and deadlines are always a challenge for her unless they relate to a high-interest activity. She is invariably good at what she does but is sensitive to perceived criticism. She is very bright but has a history of academic underachievement since middle school.

I realize you can’t diagnose her on the basis of this brief description, but I am concerned that she has been misdiagnosed. Her moods are always in response to life events: the scale and severity may seem atypical, but there is always a trigger. Can you refer me to someone who is informed and aware of the presenting symptoms and prevailing wisdom regarding treatment of ADHD (without hyperactivity)?

Please help!
Concerned Mom
p.s. My daughter runs track, which may be a mitigating factor for her not demonstrating hyperactivity.

Does this girl have bipolar disorder, ADHD, or both? Unless you entertain the diagnosis of ADHD, you’re going to miss it. Let’s look at the odds for her having a diagnosis of ADHD versus bipolar disorder or both. First, ADHD is about twice as common as bipolar disorder in both children and adults.1,2 Bipolar disorder affects only a fraction of children and adolescents with ADHD; however, among those with bipolar disorder, the likelihood of having comorbid ADHD is high.1 Several research studies have demonstrated that the earlier the mood swings of bipolar disorder start, the more likely coexisting ADHD is; 40% to 90% of children and adolescents who are diagnosed with bipolar disorder also have ADHD symptoms.3-5 Among children with ADHD, however, only 23% have bipolar disorder.6

In adults, the pattern of comorbidity is the opposite. Studies7,8 estimate that 10% to 21% of adults with bipolar disorder also have ADHD diagnosed in adulthood, while 47% of adults with ADHD have bipolar disorder. Incidence of coexisting bipolar disorder varies by ADHD presentation in adults; one study9 found that 23% of those with combined type, 6% of those with inattentive type, and 38% of those with hyperactive type ADHD also had bipolar disorder.

Second, ADHD and bipolar disorder share several features, including mood fluctuations, increased energy levels, hypertalkativeness, impulsivity, “racing thoughts,” irritability, and sleep disturbances.1,10 In addition, they both have a chronic course with life-long impairment, as well as a strong genetic component. However, ADHD and bipolar disorder can be distinguished on the basis of several differences. These include age at onset, persistence of symptoms, and qualities of the mood fluctuations, including duration, stability, and whether they are in response to real stimuli in the environment.

Third, ADHD symptoms are present throughout the lifespan. For a diagnosis, symptoms must be present (although not necessarily impairing) by age 12 years.10 Conversely, bipolar disorder can be present in young children, but such an occurrence is rare. Thus, symptoms that begin prior to puberty are more often due to ADHD. In addition, symptoms of ADHD are always present while bipolar disorder is episodic, with normal moods occurring between episodes.

Women and girls with ADHD often have strong emotional reactions to the events in their lives. This clear triggering of mood shifts by real events distinguishes ADHD from bipolar mood shifts that come and go unrelated to life events.10 Rapid ADHD mood swings are usually the result of stimuli in the environment that can shift rapidly, sometimes within minutes. However, the mood swings of bipolar disorder often occur over days or weeks even in the most “rapid cyclers.” A rapid cycling bipolar disorder is defined as one in which an individual experiences at least 4 shifts of mood over a year. Many females with ADHD have that many mood shifts in a single day!

When ADHD and bipolar disorder occur together, both must be properly diagnosed and treated in order for these girls and women to improve. Great caution must be taken to make sure you don’t miss ADHD when making a diagnosis of bipolar disorder or misdiagnose ADHD as bipolar disorder in a discouraged (or depressed) female teen or young adult. Looking at what lies beneath often will give you the answer and keep my inbox clear!

Financial disclosure:Dr Quinn is a member of the speakers board for Shire.


1. Galanter CA, Liebenluft E. Frontiers between attention deficit hyperactivity disorder and bipolar disorder. Child Adolesc Psychiatr Clin N Am. 2008;17(2):325–346. PubMed

2. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. PubMed

3. Sachs GS, Baldassano CF, Truman CJ, et al. Comorbidity of attention deficit hyperactivity disorder with early- and late-onset bipolar disorder. Am J Psychiatry. 2000;157(3):466–468. PubMed

4. Masi G, Perugi G, Toni C, et al. Attention-deficit hyperactivity disorder–bipolar comorbidity in children and adolescents. Bipolar Disord. 2006;8(4):373–381. PubMed

5. Joshi G, Wilens T. Comorbidity in pediatric bipolar disorder. Child Adolesc Psychiatr Clin N Am. 2009;18(2):291–319. PubMed

6. Beiderman J, Faraone SV, Mick E, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry. 1996;35(8):997–1008. PubMed

7. Nierenberg AA, Miyahara S, Spencer T, et al. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry. 2005;57(11):1467–1473. PubMed

8. Wingo AP, Ghaemi SN. A systematic review of rates and diagnostic validity of comorbid adult attention-deficit/hyperactivity disorder and bipolar disorder. J Clin Psychiatry. 2007 Nov;68(11):1776-1784. Full Text

9. Wilens TE, Biederman J, Faraone SV, et al. Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically referred adults with ADHD. J Clin Psychiatry. 2009;70(11):1557–1562. Full Text

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

Category: ADHD , Bipolar Disorder
Link to this post:
Related to Another Day, Another E-Mail: Looking at What Lies Beneath

One thought on “Another Day, Another E-Mail: Looking at What Lies Beneath

  1. One thing that strikes a difference from the above is “…she starts new projects with enthusiasm, but the follow-through is lacking.” Sometimes we aren’t aware of a child’s preferred learning style, and as such, we focus on the how before knowing the why. For example, why is she showing enthusiasm when starting something new, is it because she is efficacious? Her self-conscious is telling us that she believes in herself. Also, why her commitment flounders as the project progresses? Answering these and other similar questions may point you in different directions – one could be a need for different parent involvement strategies.

Leave a Reply


Browse By Author



Browse By Author

Sign-up to stay
up-to-date today!


Already registered? Sign In

Case Report

Safety and Tolerability of Concomitant Intranasal Esketamine Treatment With Irreversible, Nonselective MAOIs: A Case Series

Three cases suggest that concomitant use of intranasal esketamine with an irreversible, nonselective MAOI is safe in...