Dr Singh Offers "Clinical Clues" to Distinguish Pediatric ADHD From Mood Disorders

Manpreet K Singh, MD, MS, director, Pediatric Mood Disorders Program, Stanford University School of Medicine, California, offers "clinical clues" to clinicians on how to distinguish attention-deficit/hyperactivity disorder (ADHD) from primary mood disorders or other conditions and discusses comorbid conditions in pediatric ADHD.  Dr Singh, who is also an associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, says that mood state, the duration of the mood, and the presence of aggressive behavior are some of the indicators that clinicians should investigate when discerning ADHD from possible mood disorders.

Dr Singh recently presented a session titled "Complex comorbid ADHD: an update for all practices" at this year's Psych Congress in San Antonio, Texas.

Related content: "Treatment of ADHD Throughout the Holiday Season" With Dr Singh

Read the transcript:

Heather Flint:  Hello, Psych Congress Network, and welcome. We're here today with Dr. Manpreet Singh, and we are going to be following up on her Psych Congress 2021 conference session, where she discusses pediatric ADHD.

Dr. Singh, welcome, and can you please introduce yourself?

Dr. Manpreet Singh:  Hello. I'm delighted to be here with you, Heather, today, and to have participated in the Psych Congress activities. My name is Manpreet Singh.

I direct the Pediatric Mood Disorders Program at Stanford University and lead a team to work on how we can better advance treatments for youth with and at risk for lifelong mood disorders, like depression and bipolar disorder, that also commonly run alongside things like ADHD and anxiety. I'm delighted to talk to you today about ADHD.

Heather:  Thank you for the introduction, because that's a great way to roll into our first question, which is really, can you walk us through a little bit of some of the ways that you're able to distinguish ADHD from other mental health disorders, such as bipolar disorder?

Dr. Singh:  Absolutely. There are so many very interesting ways that our patients present. They don't make our jobs easy, I suppose, but I think that's why we receive training to be able to delineate individual symptoms as they relate to a specific disorder, and how they perhaps run across disorders, or are perhaps transdiagnostic.

Now, totally appreciate that attention problems can be found in many conditions, so there are other clues that clinicians can look for that can help them delineate whether that attention dysfunction is related to a primary mood disorder or related to a primary attention disorder, like attention deficit with hyperactivity or ADHD, or some other condition.

It's very helpful to start with understanding what the mood state of the child is. In most cases, if it's a negative mood state, then you're looking at mood disorders like disruptive mood dysregulation disorder. It's also true for intermittent explosive disorder and oppositional disorder.

If you see positive mood states, you might be curious, too, about bipolar disorder, because bipolar disorder has positive and negative moods. Attention problems also present in depression. Kids can't focus when they're sad, so it's very helpful to clarify the mood state when that attention problem is occurring.

By and large, for kids that have bread-and-butter ADHD, that doesn't run alongside any other condition, the mood is generally positive, or it's not euphoric or exaggerated, or it's not typically negative for sustained periods of time. Mood state is a very helpful clue.

The duration of the mood, whether it's a quick mood or a chronic mood like a negatively chronic irritability, that's very typical of a disruptive mood dysregulation problem. In bipolar disorder, the duration of the mood is defined by the episode.

It's very important not only to understand what the mood state is, whether it's positive or negative, but also how long it's lasting. Another aspect that can help you distinguish bread-and-butter ADHD from some of the other things that go alongside it is the presence of aggressive behavior.

Kids with ADHD who don't typically have other conditions don't stick around for a fight. Their focus is too time-limited. They lose interest or lose focus on the fight. Whereas kids with bipolar disorder might have variable levels of aggression, might rage for hours, and kids with disruptive mood dysregulation disorder or intermittent explosive disorder might demonstrate physical aggression.

Whereas kids with oppositional defiant disorder typically only show signs of verbal aggression, which is also pretty common in kids with ADHD, but again, very, very circumscribes. Kids with ODD tend to have more situational reactivity, so something like not being able to do something that they want to do leads to a very reactive outburst.

Same true for intermittent explosive disorder, where there might be an exaggeration to triggers. Whereas kids with bipolar disorder typically don't show situational variation. It's usually the episode that defines the symptom presentation.

Kids with disruptive mood dysregulation who are chronically irritable aren't really swayed by situational variations, but there can be, certainly, triggers that raise the chronic irritability towards periodic outbursts.

Finally, what's helping? When you treat ADHD first with a stimulant or behavioral management, usually, it responds well to it. ODD, DMDD, IED also show improvement in symptoms when you treat the ADHD first. Whereas in mania, you don't really see an improvement when you add psychostimulants until you first mood stabilize. That's another clue.

Sometimes, you need to add medications to a stimulant to help treat some of these disorders that run alongside ADHD, and so rational combination treatments are things that I highlighted in my talk as well, like alpha agonists for kids with oppositional defiant disorder, or mood stabilizers for disruptive mood dysregulation, intermittent explosive, or bipolar disorders.

Those are some of the clinical clues, and hopefully, practical tips that I hope are helpful for clinicians out there.

Heather:  That's excellent advice, and just bringing together all the comorbidities that you can find, what percentage of pediatric patients with ADHD do you find actually have the comorbidities?

Dr. Singh:  Heather, it's actually quite common. I think of nature as following the one-thirds, two-thirds rule. A lot of things seem to hang in that distribution. In this situation, it's about two-thirds of kids who have ADHD who also have some other co-occurring condition.

The most common of which are major depressive disorder, anxiety disorder, and oppositional defiant disorder. Although bipolar disorder, PTSD, autism can also occur alongside ADHD, but none of these diagnoses in themselves change the management of ADHD.

It's very important to be thoughtful about understanding the symptoms, when they started, what are the associated symptoms, so that you can make some rational treatment decisions, and not delay the treatment of attention problems if they are clearly the most impairing problem that is presenting.   

Dr Singh is Associate Professor of Psychiatry and Behavioral Sciences and leads a program aimed to accelerate understanding and treatment of youth with or at high risk for developing lifelong mood disorders. Dr. Singh earned her MD at Michigan State University and her MS at the University of Michigan. She completed her combined residency training in Pediatrics, Psychiatry, and Child and Adolescent Psychiatry at Cincinnati Children’s Hospital Medical Center. Dr Singh leads a multidisciplinary team that evaluates and treats youth with a spectrum of mood disorders as young as age 2 and well into their 20s. Her research examines mechanisms underlying mood disorders and applies cutting-edge strategies to directly modulate the brain using transcranial magnetic stimulation and real-time neurofeedback. She also investigates the efficacy and safety of pharmacotherapies and psychotherapies, such as family-focused psychotherapy and mindfulness meditation, to reduce mood symptoms and family stress. All of these areas of research aim to elucidate core mechanisms underlying mood disorders and how timely evaluation and treatment early in life can pave the path to more adaptive long-term outcomes.