The Boundaries Between Normality, ADHD and PBD in Child Psychiatric Clinical Practice
Attention-Deficit Hyperactivity Disorder (ADHD) is considered one of the most common neurobehavioral disorders of childhood. Clinical descriptions and diagnostic criteria for ADHD have been redefined over time; current conceptualization of the syndrome is characterized by lack of attention and/or hyperactivity-impulsivity. Epidemiological studies show large differences in the incidence, indicating that the effort of current taxonomic systems to offer diagnostic accuracy have not yielded substantial results. Bipolar Disorder (BD) with onset in childhood, commonly referred as Pediatric Bipolar Disorder (PBD), is distinguished from the adult type by the rarity of affective symptoms. Neither depressive mood nor hypomanic euphoria is apparent in the clinical picture of bipolar children and adolescents. Instead they exhibit a severe irritability and their symptoms are expressed in consecutive cycles, which include brief episodes of depressive, hypomanic, manic or mixed periods without free intervals. There has been a delay in the recognition of this clinical picture. Nevertheless, the diagnostic criteria in the current taxonomic systems are not separated from those of adults. The contemporary literature contemplates the relationship between ADHD and PBD. These two disorders share similar clinical picture with slight variations, thus the differential diagnosis in favour of PBD mainly based on the presence of affective disorders in the family. In this paper, we try to examine whether comorbidity exists, whether ADHD is over-diagnosed against PBD or whether ADHD represents a prodromal manifestation of PBD. Children with ADHD-PBD comorbidity tend to express mostly an irritable phenotype with a chronic course and have higher rates of conduct disorders. This suggests a symptomatic continuum spectrum between ADHD and PBD which is possibly responsible for the difficulties met in differential diagnosis and the variation of comorbidity rates. It seems that the earlier the onset of PBD more often it is associated with symptoms of ADHD. The relationship between PBD and ADHD has important implications for treatment. The diagnostic confusion regarding the evaluation and relationship of these two clinical entities is strongly reflected in the proposed course of pharmaceutical treatment. The diagnostic issues concerning the diagnosis of ADHD versus PBD and their entangled relationship refer to the difficulty of defining the limits of normal and abnormal in the mental health of children and adolescents and the limitation of the taxonomic systems in respect to the particularities of this developmental age spectrum.
Attention-Deficit Hyperactivity Disorder (ADHD), Pediatric Bipolar Disorder (PBD), Comorbidity, Diagnostic Issues, Limitations, Normality
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