ADHD with Bipolar Disorder in Girls
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Background: Prior work has shown a relationship between ADHD and bipolar disorder (BPD). Systematic studies of children and adolescents show that the rates of ADHD range from 57 to 98% in pts with bipolar disorder (Borchardt and Bernstein, 1995; Geller et al., 1995; West et al., 1995; Wozniak et al., 1995a) and that the rates of bipolar disorder range from 11 to 22% in ADHD pts (Butler et al., 1995; Biederman et al, 1996b). However, there is little information known about the relationship and presence of both ADHD and BPD in pts, which the authors term ADHD + BPD. They began to investigate this issue in a sample of consecutively referred pre-adolescent children with BPD. Would these children and their relatives be at high risk for ADHD? Also, could ADHD + BPD be a familiarly distinct subtype of BPD? Their original work was on boys, which did suggest that comorbid ADHD with BPD is familiarly distinct from other forms of ADHD. Then they began investigating this relationship in girls.
Methods:
Subjects: 140 ADHD probands and 122 non-ADHD comparisons with 417 and 369 first degree biological relatives respectively. The two ADHD proband groups and the control group were similar in terms of SES, intactness of family, gender, and age of relatives.
Procedures: DSM-III-R based structured interviews and diagnostic assessments of parents were based on direct interviews with each parent using the SCID or through an indirect interview with the available parent from that family. Ninety two percent of the control parents and 88% of the ADHD parents were directly interviewed.
Hypotheses to be tested:
- ADHD and BPD are independent and co-occur due to chance.
- ADHD + BPD is a distinct subtype or a completely separate condition. Also, co segregation should be found: among relatives of ADHD + BPD children, the presence of one disorder should predict the presence of the other.
- ADHD and BPD co-occur due to nonrandom mating.
- Predicts higher risks for ADHD and BPD among relatives of ADHD + BPD compared with relatives of ADHD w/o BPD probands.
- ADHD children with and w/o BPD share common familial etiologic factors, but differ due to environmental effects.
- Posits that the BPD among ADHD children is secondary to ADHD.
- Posits that the ADHD among BPD children is secondary to BPD.
Statistical analysis: Adjusted analyses for the non-independence of siblings by using the Huber formula and then logistic regression to compare groups on the prevalence and family history of the disorders of interest. Additionally, to test for assertive mating they used the entire ADHD sample to determine if ADHD in one spouse was predictive of BPD in the other spouse.
Results: Fifteen (11%) of the ADHD probands met criteria for BPD.
- Rates of ADHD were elevated among relatives of both types of ADHD probands compared to controls (P value <0.001), but BPD was elevated only among relatives of ADHD + BPD probands compared to controls.
- The risk for any ADHD + BPD was highest among relatives of ADHD + BPD probands, but the difference was not statistically significant.
- ADHD w/o BPD was highest among relatives of ADHD probands w/o BPD (P < 0.001).
- Weak evidence for co segregation between ADHD and BPD.
- No evidence for a trend of random mating between ADHD parents and those with mania.
Comments/Limitations: Partially consistent with hypothesis number two. Results reject hypotheses that assume all ADHD children have some familial risk for BPD. Findings also reject hypotheses that attribute either disorder to be a secondary manifestation of the other. It is important to recognize that further work investigating the validity of a syndrome that exhibits childhood onset BPD, ADHD and high familial risks for ADHD + BPD is necessary. Limitations include the fact that only 5 of the 15 probands with ADHD + BPD were directly interviewed, other psychiatric illnesses which may have accounted for some of the s/s reported were not assessed (ex. PTSD), and there was a limited number of pts included with ADHD + BPD. Further work is necessary to determine the full relationship between ADHD, BPD, and a possible subtype. This will have clinical and research implications which may be very critical in the future
Presented by Alyson Kuroski, DO
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